Woman standing near window, worrying

Anxiety is one of the most common mental health concerns, affecting millions of people worldwide. An estimated 19.1% of U.S. adults had any anxiety disorder in the past year. While everyone experiences some level of anxiety occasionally, for many individuals, overwhelming, recurring, or unexpected anxiety can profoundly impact daily life. When anxiety becomes persistent and interferes with normal functioning, professional support through therapy can provide significant relief and help restore quality of life.

Anxiety disorders are now recognized as the most prevalent mental health conditions globally, with about a third of U.S. adolescents and adults experiencing an anxiety disorder at some point in their lives. Understanding anxiety—its symptoms, causes, and available treatments—is crucial for those experiencing these challenges and their loved ones seeking to provide support.

Table of Contents

  • What Is Anxiety?
  • Signs and Symptoms of Anxiety
  • Understanding Different Presentations of Anxiety
  • Generalized Anxiety Disorder
  • What Causes Anxiety?
  • Types of Anxiety Disorders
  • Anxiety in Children and Adolescents
  • The Neurobiology of Anxiety
  • Evidence-Based Treatments
  • Frequently Asked Questions
  • How Therapy Can Help

What Is Anxiety?

Anxiety is a natural emotional response characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure. While anxiety serves an evolutionary purpose—helping us detect and respond to threats—it becomes problematic when it's excessive, persistent, or occurs without clear cause. Anxiety can manifest as nervousness, worry, or self-doubt, and its intensity can range from mild uneasiness to overwhelming dread that significantly impairs daily functioning.

Fear is "a hypothetical cause [motivation] of behavior" and its main purpose is to keep organisms alive. Thus, predators (in animals) and perpetrators (in humans), electric shocks (both animals and humans), and stimulation of specific brain regions that produce defensive reflexes—such as the PAG (periaqueductal gray), hypothalamus, and amygdala—would satisfy the objective criterion of fear. Of course, the subjective experience of fear would differ between humans and animals, but this would hold true for almost all biological processes, such as pain, hunger, etc.

Signs and Symptoms of Anxiety

Anxiety affects people on multiple levels—emotional, cognitive, physical, and behavioral. The symptoms can vary significantly from person to person, making diagnosis dependent on individual experiences and feelings of worry.

Emotional and Cognitive Symptoms

  • Persistent worry or dread
  • Feeling confused or having difficulty concentrating
  • Intrusive or obsessive thoughts
  • Feeling restless, frustrated, or irritable
  • 66% of U.S. LGBTQ+ young people ages 13-24 reported experiencing recent symptoms of anxiety in 2023

Physical Symptoms

Anxiety frequently manifests through physical symptoms, including:

  • Overly tense muscles or high blood pressure
  • Trembling, sweating, or racing heartbeat
  • Dizziness and insomnia
  • Headaches and digestive problems
  • Difficulty breathing and nausea

When physical symptoms are severe and sudden, they may indicate a panic attack—an intense surge of fear or discomfort that peaks within minutes.

Behavioral Symptoms

  • Avoidance of anxiety-provoking situations
  • Social withdrawal or self-isolation
  • Seeking reassurance from others
  • Safety behaviors (actions taken to prevent feared outcomes)

Understanding Different Presentations of Anxiety

Anxiety can manifest differently across individuals, making it important not to assume someone's experience based on outward appearances. Some people with anxiety may become more talkative, while others withdraw. Even individuals who appear outgoing, friendly, or fearless can experience significant anxiety.

It's crucial to understand that variation in emotion is likely continuous on multiple dimensions, including intensity, qualitative aspects of subjective experience, cognitive content, physiological state, and behavioral characteristics. Nonetheless, there is value in creating distinct emotional categories by labeling particular combinations of emotional signs and symptoms.

Supporting Someone with Anxiety

If you suspect someone you know is experiencing anxiety, consider these supportive approaches:

  • Be patient and understanding
  • Share words of encouragement or appreciation
  • Be predictable and willing to share details if asked
  • Avoid pressuring them to "just relax" or minimize their concerns

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD), also known as free-floating anxiety, involves chronic feelings of worry and doom without a specific cause. An estimated 2.7% of U.S. adults had generalized anxiety disorder in the past year.

DSM-5-TR Diagnostic Criteria for GAD

According to the DSM-5-TR, GAD is characterized by:

  • Excessive worry occurring more days than not for at least 6 months
  • Difficulty controlling the worry
  • The anxiety is associated with at least three of the following symptoms:
  • Frequent fatigue
  • Restlessness or feeling on edge
  • Irritability
  • Difficulty concentrating or mind going blank
  • Sleep problems (difficulty falling or staying asleep, or restless sleep)
  • Muscle tension

Given the evidence for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

What Causes Anxiety?

Anxiety, like the body's fight-flight-or-freeze response, evolved for survival by helping humans detect and avoid danger. However, when anxiety becomes excessive or occurs without real threat, it can significantly impair functioning.

Biological Factors

  • Genetics: Genetic investigations have identified conserved risk variants in genes like BDNF and GABRA2, which modulate amygdala reactivity and stress resilience across species
  • Brain chemistry: Imbalances in neurotransmitters like serotonin, GABA, and norepinephrine
  • Temperament: Some individuals are born with a more anxious temperament

Environmental Factors

Both biology and environment determine whether someone develops anxiety. Anxious behavior can be inherited, learned, or both. Research shows that anxious parents are more likely to have anxious children, though this may result from both genetic factors and learned behaviors.

Key environmental contributors include:

  • Early life stress: Research has shown that early-life stress can lead to alterations in brain structures and neurotransmitter systems, as well as epigenetic changes that affect gene expression. These changes can result in heightened sensitivity to stress and increased vulnerability to anxiety.
  • Traumatic experiences: Unresolved trauma can leave individuals in a heightened state of physiological arousal
  • Stressful life events: Major life changes, losses, or ongoing stressors
  • Social factors: Limited social support or high-stress environments

Modern Life and Anxiety

Contemporary factors contributing to anxiety include:

  • Fast-paced lifestyles and constant connectivity
  • Social media and digital overwhelm
  • Academic or work pressure
  • Economic uncertainty
  • From 1990 to 2021, the global incidence of anxiety disorders among those aged 10-24 years increased by 52%, particularly in the 10-14 age group and post-2019.

Types of Anxiety Disorders

The DSM-5-TR classifies several distinct anxiety disorders, each with specific diagnostic criteria:

1. Separation Anxiety Disorder

Characterized by excessive fear or anxiety about separation from attachment figures. While traditionally considered a childhood disorder, the DSM-5-TR recognizes that it can develop in adulthood as well. In contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18. A duration criterion—"typically lasting for 6 months or more"—has been added for adults to minimize overdiagnosis of transient fears.

2. Selective Mutism

Consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations. This condition is now classified as an anxiety disorder in DSM-5-TR.

3. Panic Disorder

Recurrent, unexpected panic attacks followed by persistent concern about having additional attacks or their consequences. Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria. The co-occurrence of panic disorder and agoraphobia is now coded with two diagnoses.

4. Specific Phobias

Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) that is out of proportion to the actual danger posed.

5. Social Anxiety Disorder (Social Phobia)

An estimated 7.1% of U.S. adults had social anxiety disorder in the past year. Individuals with social anxiety experience intense fear or anxiety in social situations where they might be scrutinized by others.

6. Agoraphobia

Fear or anxiety about being in situations where escape might be difficult or help unavailable if panic-like symptoms occur. This includes using public transportation, being in open or enclosed spaces, standing in line or being in crowds, or being outside the home alone.

7. Substance/Medication-Induced Anxiety Disorder

Anxiety symptoms that are a direct result of intoxication, withdrawal, or exposure to a medication or substance.

Anxiety in Children and Adolescents

Anxiety disorders are highly prevalent among young people, with distinct developmental considerations:

Prevalence and Impact

  • An estimated 31.9% of adolescents had any anxiety disorder. Of adolescents with any anxiety disorder, an estimated 8.3% had severe impairment.
  • The prevalence of any anxiety disorder among adolescents was higher for females (38.0%) than for males (26.1%).
  • In 2023, approximately 16.1% of 12- to 17-year-olds had a current anxiety diagnosis, while 31.9% will experience an anxiety disorder at some point during their teen years.

Unique Presentations in Youth

Children and adolescents may show different anxiety symptoms than adults:

  • Difficulty attending school or avoiding school altogether
  • Avoidance of social events or extracurricular activities
  • Being behind peers in social development or independence
  • Physical symptoms like stomachaches or headaches
  • Crying, clinging to parents, or tantrums
  • Repetitive behaviors that mimic obsessions or compulsions

Anxiety and Academic Performance

There were differences in school and social life indicators between adolescents with a current, diagnosed mental or behavioral health condition (anxiety, depression, or behavior/conduct problems) and those without a current diagnosis. Anxious youth often struggle with:

  • Decreased school engagement
  • Difficulty completing homework
  • Increased absences
  • Social difficulties and bullying

Co-occurring Concerns

Eating Disorders and Anxiety

Recent research shows strong connections between anxiety and eating disorders in adolescents:

  • Eating disorders frequently accompany various psychiatric conditions, notably mood and anxiety disorders, obsessive-compulsive disorder, and alcohol or substance use disorders.
  • Anxiety symptoms were associated with subsequent eating disorder symptoms, increases in eating disorder symptoms, and higher odds of eating disorders, including their onset.
  • When the likelihood of anxiety disorders was significantly higher in ARFID (OR 1.52), then OCD was much higher in those with AN (OR 2.14) followed by BN (OR 1.79) and ARFID (OR 1.74).

The COVID-19 pandemic significantly impacted both anxiety and eating disorders:

  • There has been a significant increase in both the diagnosis of eating disorders and the display of related behaviors in young individuals who were previously diagnosed, a trend observed since the pandemic's outset. This increase has been attributed to maladaptive methods of asserting control in the face of uncertainty, coupled with sensations of isolation and disruptions to established routines.

The Neurobiology of Anxiety

Understanding the brain mechanisms underlying anxiety has advanced significantly with modern neuroimaging and research techniques.

Key Brain Regions

Major anxiety-related brain regions include the BNST, amygdala, LHb, HPC and others, and their connectivity, highlighting their roles in the neurobiological mechanisms underlying anxiety.

The primary brain structures involved in anxiety include:

  • Amygdala: Central to fear processing and emotional memory
  • Prefrontal cortex: Involved in emotion regulation and executive control
  • Hippocampus: Important for memory and contextual processing
  • Periaqueductal gray (PAG): Coordinates defensive responses

Neural Circuit Dysfunction

Recent research reveals specific neural circuit abnormalities in anxiety:

  • Researchers have discovered a specific set of neurons in the amygdala that can trigger anxiety and social deficits when overactive. By restoring the excitability balance in this brain region, they successfully reversed these symptoms in mice. Overactive neurons in the amygdala were found to drive anxiety and social withdrawal, but rebalancing their activity reversed these effects in mice.
  • Anxiety disorders are associated with altered connectivity in large-scale intrinsic brain networks. It remains uncertain how much these signatures overlap across different phenotypes due to a lack of well-powered cross-disorder comparisons. We used resting-state functional magnetic resonance imaging to investigate differences in functional connectivity.

Neurotransmitter Systems

Multiple neurotransmitter systems contribute to anxiety:

  • GABA: GABA is the primary inhibitory neurotransmitter in the brain, responsible for reducing neuronal excitability and promoting relaxation. Dysfunction in the GABAergic system can lead to increased neuronal activity and heightened anxiety. Research has shown that individuals with anxiety disorders may have reduced GABA levels or altered GABA receptor function.
  • Serotonin: Involved in mood regulation and emotional processing
  • Norepinephrine: Norepinephrine, also known as noradrenaline, is a neurotransmitter involved in the body's "fight or flight" response. It plays a role in arousal, alertness, and stress response. Hyperactivity in the noradrenergic system is associated with increased anxiety and panic symptoms.
  • Glutamate: The brain's primary excitatory neurotransmitter

Interoception and Anxiety

Pathological anxiety stems from computational failures in interoception, where rigid threat beliefs amplify prediction errors. This suggests that anxiety disorders involve disruptions in how the brain processes internal bodily signals and predicts future states.

Evidence-Based Treatments

Cognitive Behavioral Therapy (CBT)

CBT remains the gold-standard psychological treatment for anxiety disorders across all ages:

Effectiveness in Adults

  • Given the evidence for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD.
  • Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95% CI: 0.76 to 1.0). Effects remained robust across sensitivity analyses.
  • The findings demonstrated small placebo-controlled effects of CBT on target disorder symptoms (Hedges' g = 0.24, p < 0.05). When examining only PTSD studies, effects were reduced (Hedges' g = 0.14, p < 0.05).

CBT for Children and Adolescents

  • Both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication have considerable empirical support as safe and effective short-term treatments for anxiety in children and adolescents.
  • 77.1% of participants at posttreatment and 81.9% at follow-up showed significant improvements in target symptom measures compared to pretreatment. Youth in CBT had a remission rate of 49.4% compared to 17.8% for those in waitlist or no treatment conditions.

Brain Changes with CBT

Treatment with cognitive behavioral therapy (CBT) led to improvements in clinical symptoms and brain functioning. Following three months of CBT treatment, children with anxiety showed a clinically significant decrease in anxiety symptoms and improved functioning. Increased activation seen before treatment in many frontal and parietal brain regions also improved after CBT, declining to levels equal to or lower than those of non-anxious children.

Components of Effective CBT

The goal of emotional awareness training is for children to recognize somatic, behavioral, and cognitive cues of anxiety so that they use other anxiety management techniques more effectively. Children are taught strategies to recognize their anxiety, distinguish anxiety from other feelings, and use the Subjective Units of Distress Scale (SUDS) to rate anxiety severity, which is often rated from 0 (no anxiety) to 10 (maximum anxiety).

Key components include:

  • Psychoeducation about anxiety and its mechanisms
  • Cognitive restructuring to identify and modify anxious thoughts
  • Exposure therapy to gradually face feared situations
  • Relaxation training and coping skills
  • Relapse prevention strategies

Physical Activity and Exercise

Physical activity had medium effects on depression (median effect size=-0.43, IQR=-0.66 to -0.27), anxiety (median effect size=-0.42, IQR=-0.66 to -0.26), and psychological distress (effect size=-0.60, 95% CI -0.78 to -0.42), compared with usual care across all populations.

The pooled analysis found moderate effect sizes favoring exercise for symptoms of anxiety (SMD = −0.39, 95% CI = −0.61 to −0.17, I2 = 68.1%, p <.01, n = 55 RCTs, n = 24,797 participants).

Medication Options

While psychotherapy is often the first-line treatment, medications can be helpful, particularly for severe anxiety or when combined with therapy:

For Adults

  • SSRIs (Selective Serotonin Reuptake Inhibitors): First-line medications
  • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): Alternative first-line options
  • Benzodiazepines: For short-term relief of acute symptoms (used cautiously due to dependence risk)
  • Beta-blockers: For physical symptoms of anxiety

For Children and Adolescents

Serotonin norepinephrine reuptake inhibitor (SNRI) medication has some empirical support as an additional treatment option. Medication is typically considered when:

  • Symptoms are severe and impairing
  • Therapy alone has not been sufficient
  • Combined treatment may enhance outcomes

Digital Mental Health Interventions

Digital mental health interventions (DMHIs) offer accessible and effective treatments such as digital mental health interventions (DMHIs).

Participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4% (n=70) of adolescents with elevated SCOFF scores.

Emerging and Alternative Treatments

  • Acceptance and Commitment Therapy (ACT): Acceptance and Commitment Therapy was the most effective intervention for treating anxiety disorders in children and adolescents
  • Mindfulness-based interventions: Show promise for anxiety reduction
  • Neurostimulation approaches: Transcranial magnetic stimulation (TMS), which enhances PFC inhibitory control over the amygdala, has demonstrated efficacy in reducing anxiety symptoms in clinical trials. Deep brain stimulation (DBS) of the BNST is being explored to normalize hyperactive anxiety circuits in treatment-resistant cases.
  • Novel pharmacological targets: Drugs targeting the glutamatergic system, particularly NMDA receptors, have shown promise. Ketamine, a non-competitive NMDA receptor antagonist, has gained attention for its rapid and robust anxiolytic effects. In animal studies, ketamine reduces anxiety-like behavior and has shown similar efficacy in humans.

Frequently Asked Questions

1. How do I know if my anxiety is normal or if I need help?

While everyone experiences anxiety, you should consider seeking help if:

  • Your anxiety persists for several weeks or months
  • It interferes with work, school, or relationships
  • You avoid important activities due to anxiety
  • Physical symptoms are impacting your health
  • You're using substances to cope

2. Can anxiety be cured completely?

While anxiety disorders are highly treatable, the goal is typically management rather than "cure." Many people learn to manage their anxiety effectively and live fulfilling lives. Individuals who complete CBT for anxiety disorders are less likely to experience symptom relapse than those who rely solely on medication. The focus on cognitive restructuring, behavioral change, and emotional regulation ensures that individuals can continue to apply the principles of CBT to maintain their mental health over time.

3. How long does anxiety treatment typically take?

Treatment duration varies by individual and disorder type. CBT typically involves 12-20 weekly sessions, though some people benefit from shorter or longer treatment. Individuals often experience significant reductions in fear and avoidance behaviors after just a few sessions of exposure-based CBT.

4. Can children outgrow anxiety disorders?

Without treatment, childhood anxiety often persists into adulthood. However, early intervention can be highly effective. Anxiety disorders in the pediatric years can predict a lifelong mental-health struggle. That's why early identification and treatment are crucial.

5. Is online therapy effective for anxiety?

Yes, research shows that online therapy can be as effective as in-person treatment for many anxiety disorders. E-mental health interventions are convenient and multifunctional and are effective in enhancing the well-being of healthcare professionals.

6. Should I try medication or therapy first?

This decision should be made with a healthcare provider based on your specific situation. There is evidence that CBT is an effective adjunct treatment to psychopharmacological interventions, and the combination of treatments may be most effective for some youth. Many people benefit from therapy alone, while others find combination treatment most helpful.

How Therapy Can Help

If you're struggling with anxiety, know that effective help is available. Research consistently shows that therapy, particularly CBT, can provide significant and lasting relief from anxiety symptoms. Find a therapist who specializes in anxiety disorders and take the first step toward feeling better.

A qualified therapist can help you:

  • Understand your specific anxiety patterns
  • Develop personalized coping strategies
  • Learn to challenge anxious thoughts
  • Gradually face feared situations safely
  • Build confidence and resilience
  • Address any co-occurring concerns

Remember, seeking help is a sign of strength, not weakness. With proper treatment and support, most people with anxiety disorders can achieve significant improvement and lead fulfilling lives.

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