Anxiety

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Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often

accompanied by nervous behavior such as pacing back and forth, somatic complaints, and
rumination.[1] It is the subjectively unpleasant feelings of dread over anticipated events.[2][need
quotation to verify]

Anxiety is a feeling of uneasiness and worry, usually generalized and unfocused as an

overreaction to a situation that is only subjectively seen as menacing.[3] It is often
accompanied by muscular tension,[4] restlessness, fatigue and problems in concentration.
Anxiety is closely related to fear, which is a response to a real or perceived immediate threat;
anxiety involves the expectation of future threat.[4] People facing anxiety may withdraw from
situations which have provoked anxiety in the past.[5]

Anxiety disorders differ from developmentally normative fear or anxiety by being excessive
or persisting beyond developmentally appropriate periods. They differ from transient fear or
anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months or more),
although the criterion for duration is intended as a general guide with allowance for some
degree of flexibility and is sometimes of shorter duration in children.[4]

Contents
 1 Anxiety vs. fear
  2 Symptoms
 3 Types
o 3.1 Existential
o 3.2 Test and performance
o 3.3 Stranger, social, and intergroup anxiety
o 3.4 Trait
o 3.5 Choice or decision
o 3.6 Panic Disorder
o 3.7 Anxiety disorders
o 3.8 Short- and long-term anxiety
 4 Co-morbidity
 5 Risk factors
o 5.1 Neuroanatomy
 5.1.1 The gut-brain axis
o 5.2 Genetics
o 5.3 Medical conditions
o 5.4 Substance-induced
o 5.5 Psychological
 5.5.1 Evolutionary psychology
o 5.6 Social
 5.6.1 Gender socialization
 6 Treatment
 7 Prevention
 8 Pathophysiology
 9 See also
 10 References
 11 External links

Anxiety vs. fear

A job applicant with a worried facial expression

Anxiety is distinguished from fear, which is an appropriate cognitive and emotional response
to a perceived threat.[6] Anxiety is related to the specific behaviors of fight-or-flight responses,
defensive behavior or escape. It occurs in situations only perceived as uncontrollable or
unavoidable, but not realistically so.[7] David Barlow defines anxiety as "a future-oriented
mood state in which one is not ready or prepared to attempt to cope with upcoming negative
events,"[8] and that it is a distinction between future and present dangers which divides anxiety
and fear. Another description of anxiety is agony, dread, terror, or even apprehension.[9] In
positive psychology, anxiety is described as the mental state that results from a difficult
challenge for which the subject has insufficient coping skills.[10]

Fear and anxiety can be differentiated in four domains: (1) duration of emotional experience,
(2) temporal focus, (3) specificity of the threat, and (4) motivated direction. Fear is short-
lived, present-focused, geared towards a specific threat, and facilitating escape from threat;
anxiety, on the other hand, is long-acting, future-focused, broadly focused towards a diffuse
threat, and promoting excessive caution while approaching a potential threat and interferes
with constructive coping.[11]
Joseph E. LeDoux and Lisa Feldman Barrett have both sought to separate automatic threat
responses from additional associated cognitive activity within anxiety.[12][13]

Symptoms
Anxiety can be experienced with long, drawn-out daily symptoms that reduce quality of life,
known as chronic (or generalized) anxiety, or it can be experienced in short spurts with
sporadic, stressful panic attacks, known as acute anxiety.[14] Symptoms of anxiety can range
in number, intensity, and frequency, depending on the person. While almost everyone has
experienced anxiety at some point in their lives, most do not develop long-term problems with
anxiety.

Anxiety may cause psychiatric and physiological symptoms.[15][16]

The risk of anxiety leading to depression could possibly even lead to an individual harming
themselves, which is why there are many 24-hour suicide prevention hotlines.[17]

The behavioral effects of anxiety may include withdrawal from situations which have
provoked anxiety or negative feelings in the past.[5] Other effects may include changes in
sleeping patterns, changes in habits, increase or decrease in food intake, and increased motor
tension (such as foot tapping).[5]

The emotional effects of anxiety may include "feelings of apprehension or dread, trouble
concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness,
watching (and waiting) for signs (and occurrences) of danger, and, feeling like your mind's
gone blank"[18] as well as "nightmares/bad dreams, obsessions about sensations, déjà vu, a
trapped-in-your-mind feeling, and feeling like everything is scary."[19]

The cognitive effects of anxiety may include thoughts about suspected dangers, such as fear
of dying. "You may ... fear that the chest pains are a deadly heart attack or that the shooting
pains in your head are the result of a tumor or an aneurysm. You feel an intense fear when
you think of dying, or you may think of it more often than normal, or can't get it out of your
mind."[20]

The physiological symptoms of anxiety may include:[15][16]

 Neurological, as headache, paresthesias, fasciculations, vertigo, or presyncope.

 Digestive, as abdominal pain, nausea, diarrhea, indigestion, dry mouth, or bolus.
 Respiratory, as shortness of breath or sighing breathing.
 Cardiac, as palpitations, tachycardia, or chest pain.
 Muscular, as fatigue, tremors, or tetany.
 Cutaneous, as perspiration, or itchy skin.
 Uro-genital, as frequent urination, urinary urgency, dyspareunia, or impotence, chronic
pelvic pain syndrome. Stress hormones released in an anxious state have an impact on bowel
function and can manifest physical symptoms that may contribute to or exacerbate IBS.

Types
Painting entitled Anxiety, 1894, by Edvard Munch

There are various types of anxiety. Existential anxiety can occur when a person faces angst,
an existential crisis, or nihilistic feelings. People can also face mathematical anxiety, somatic
anxiety, stage fright, or test anxiety. Social anxiety refers to a fear of rejection and negative
evaluation by other people.[21]

Existential

Further information: Angst, Existential crisis, and Nihilism

The philosopher Søren Kierkegaard, in The Concept of Anxiety (1844), described anxiety or
dread associated with the "dizziness of freedom" and suggested the possibility for positive
resolution of anxiety through the self-conscious exercise of responsibility and choosing. In Art
and Artist (1932), the psychologist Otto Rank wrote that the psychological trauma of birth
was the pre-eminent human symbol of existential anxiety and encompasses the creative
person's simultaneous fear of – and desire for – separation, individuation, and
differentiation.[citation needed]

The theologian Paul Tillich characterized existential anxiety[22] as "the state in which a being
is aware of its possible nonbeing" and he listed three categories for the nonbeing and resulting
anxiety: ontic (fate and death), moral (guilt and condemnation), and spiritual (emptiness and
meaninglessness). According to Tillich, the last of these three types of existential anxiety, i.e.
spiritual anxiety, is predominant in modern times while the others were predominant in earlier
periods. Tillich argues that this anxiety can be accepted as part of the human condition or it
can be resisted but with negative consequences. In its pathological form, spiritual anxiety may
tend to "drive the person toward the creation of certitude in systems of meaning which are
supported by tradition and authority" even though such "undoubted certitude is not built on
the rock of reality".[22]

According to Viktor Frankl, the author of Man's Search for Meaning, when a person is faced
with extreme mortal dangers, the most basic of all human wishes is to find a meaning of life
to combat the "trauma of nonbeing" as death is near.[23]

Depending on the source of the threat, psychoanalytic theory distinguishes the following types
of anxiety:
  realistic
 neurotic
 moral[24]

Test and performance

Main articles: Test anxiety, Mathematical anxiety, Stage fright, and Somatic anxiety

According to Yerkes-Dodson law, an optimal level of arousal is necessary to best complete a

task such as an exam, performance, or competitive event. However, when the anxiety or level
of arousal exceeds that optimum, the result is a decline in performance.[25]

Test anxiety is the uneasiness, apprehension, or nervousness felt by students who have a fear
of failing an exam. Students who have test anxiety may experience any of the following: the
association of grades with personal worth; fear of embarrassment by a teacher; fear of
alienation from parents or friends; time pressures; or feeling a loss of control. Sweating,
dizziness, headaches, racing heartbeats, nausea, fidgeting, uncontrollable crying or laughing
and drumming on a desk are all common. Because test anxiety hinges on fear of negative
evaluation,[26] debate exists as to whether test anxiety is itself a unique anxiety disorder or
whether it is a specific type of social phobia.[27] The DSM-IV classifies test anxiety as a type
of social phobia.[28]

While the term "test anxiety" refers specifically to students,[29] many workers share the same
experience with regard to their career or profession. The fear of failing at a task and being
negatively evaluated for failure can have a similarly negative effect on the adult.[30]
Management of test anxiety focuses on achieving relaxation and developing mechanisms to
manage anxiety.[29]

Stranger, social, and intergroup anxiety

Main articles: Stranger anxiety and Social anxiety

Humans generally require social acceptance and thus sometimes dread the disapproval of
others. Apprehension of being judged by others may cause anxiety in social environments.[31]

Anxiety during social interactions, particularly between strangers, is common among young
people. It may persist into adulthood and become social anxiety or social phobia. "Stranger
anxiety" in small children is not considered a phobia. In adults, an excessive fear of other
people is not a developmentally common stage; it is called social anxiety. According to
Cutting,[32] social phobics do not fear the crowd but the fact that they may be judged
negatively.

Social anxiety varies in degree and severity. For some people, it is characterized by
experiencing discomfort or awkwardness during physical social contact (e.g. embracing,
shaking hands, etc.), while in other cases it can lead to a fear of interacting with unfamiliar
people altogether. Those suffering from this condition may restrict their lifestyles to
accommodate the anxiety, minimizing social interaction whenever possible. Social anxiety
also forms a core aspect of certain personality disorders, including avoidant personality
disorder.[33]
To the extent that a person is fearful of social encounters with unfamiliar others, some people
may experience anxiety particularly during interactions with outgroup members, or people
who share different group memberships (i.e., by race, ethnicity, class, gender, etc.).
Depending on the nature of the antecedent relations, cognitions, and situational factors,
intergroup contact may be stressful and lead to feelings of anxiety. This apprehension or fear
of contact with outgroup members is often called interracial or intergroup anxiety.[34]

As is the case the more generalized forms of social anxiety, intergroup anxiety has behavioral,
cognitive, and affective effects. For instance, increases in schematic processing and simplified
information processing can occur when anxiety is high. Indeed, such is consistent with related
work on attentional bias in implicit memory.[35][36][37] Additionally recent research has found
that implicit racial evaluations (i.e. automatic prejudiced attitudes) can be amplified during
intergroup interaction.[38] Negative experiences have been illustrated in producing not only
negative expectations, but also avoidant, or antagonistic, behavior such as hostility.[39]
Furthermore, when compared to anxiety levels and cognitive effort (e.g., impression
management and self-presentation) in intragroup contexts, levels and depletion of resources
may be exacerbated in the intergroup situation.

Trait

Anxiety can be either a short-term 'state' or a long-term personality "trait". Trait anxiety
reflects a stable tendency across the lifespan of responding with acute, state anxiety in the
anticipation of threatening situations (whether they are actually deemed threatening or not).[40]
A meta-analysis showed that a high level of neuroticism is a risk factor for development of
anxiety symptoms and disorders.[41] Such anxiety may be conscious or unconscious.[42]

Personality can also be a trait leading to anxiety and depression. Through experience, many
find it difficult to collect themselves due to their own personal nature.[43]

Choice or decision

Anxiety induced by the need to choose between similar options is increasingly being
recognized as a problem for individuals and for organizations.[44] In 2004, Capgemini wrote:
"Today we're all faced with greater choice, more competition and less time to consider our
options or seek out the right advice."[45]

In a decision context, unpredictability or uncertainty may trigger emotional responses in

anxious individuals that systematically alter decision-making.[46] There are primarily two
forms of this anxiety type. The first form refers to a choice in which there are multiple
potential outcomes with known or calculable probabilities. The second form refers to the
uncertainty and ambiguity related to a decision context in which there are multiple possible
outcomes with unknown probabilities.[46]

Panic Disorder

Main article: Panic disorder

Panic disorder may share symptoms of stress and anxiety, but it is actually very different.
Panic disorder is an anxiety disorder that occurs without any triggers. According to the U.S
Department of Health and Human Services, this disorder can be distinguished by unexpected
and repeated episodes of intense fear.[47] Someone who suffers from panic disorder will
eventually develop constant fear of another attack and as this progresses it will begin to affect
daily functioning and an individual's general quality of life. It is reported by the Cleveland
Clinic that panic disorder affects 2 to 3 percent of adult Americans and can begin around the
time of the teenage and early adult years. Some symptoms include: difficulty breathing, chest
pain, dizziness, trembling or shaking, feeling faint, nausea, fear that you are losing control or
are about to die. Even though they suffer from these symptoms during an attack, the main
symptom is the persistent fear of having future panic attacks.[48]

Anxiety disorders

Main article: Anxiety disorder

Anxiety disorders are a group of mental disorders characterized by exaggerated feelings of

anxiety and fear responses.[49] Anxiety is a worry about future events and fear is a reaction to
current events. These feelings may cause physical symptoms, such as a fast heart rate and
shakiness. There are a number of anxiety disorders: including generalized anxiety disorder,
specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic
disorder, and selective mutism. The disorder differs by what results in the symptoms. People
often have more than one anxiety disorder.[49]

Anxiety disorders are caused by a complex combination of genetic and environmental

factors.[citation needed] To be diagnosed, symptoms typically need to be present for at least six
months, be more than would be expected for the situation, and decrease a person's ability to
function in their daily lives.[citation needed] Other problems that may result in similar symptoms
include hyperthyroidism, heart disease, caffeine, alcohol, or cannabis use, and withdrawal
from certain drugs, among others.[50]

Without treatment, anxiety disorders tend to remain.[49][51] Treatment may include lifestyle
changes, counselling, and medications. Counselling is typically with a type of cognitive
behavioural therapy.[52] Medications, such as antidepressants or beta blockers, may improve
symptoms.[51]

About 12% of people are affected by an anxiety disorder in a given year and between 5–30%
are affected at some point in their life.[52][53] They occur about twice as often in women than
they do in men, and generally begin before the age of 25.[49][52] The most common are specific
phobia which affects nearly 12% and social anxiety disorder which affects 10% at some point
in their life. They affect those between the ages of 15 and 35 the most and become less
common after the age of 55. Rates appear to be higher in the United States and Europe.[52]

Short- and long-term anxiety

Anxiety can be either a short-term "state" or a long-term "trait". Whereas trait anxiety
represents worrying about future events, anxiety disorders are a group of mental disorders
characterized by feelings of anxiety and fear.[49]

Co-morbidity
Anxiety disorders often occur with other mental health disorders, particularly major
depressive disorder, bipolar disorder, eating disorders, or certain personality disorders. It also
commonly occurs with personality traits such as neuroticism. This observed co-occurrence is
partly due to genetic and environmental influences shared between these traits and
anxiety.[54][55]

Anxiety is often experienced by those with obsessive–compulsive disorder and is an acute

presence in panic disorder.

Risk factors

A marble bust of the Roman Emperor Decius from the Capitoline Museum. This portrait "conveys an
impression of anxiety and weariness, as of a man shouldering heavy [state] responsibilities".[56]

Anxiety disorders are partly genetic, with twin studies suggesting 30-40% genetic influence
on individual differences in anxiety.[57] Environmental factors are also important. Twin
studies show that individual-specific environments have a large influence on anxiety, whereas
shared environmental influences (environments that affect twins in the same way) operate
during childhood but decline through adolescence.[58] Specific measured ‘environments’ that
have been associated with anxiety include child abuse, family history of mental health
disorders, and poverty.[59] Anxiety is also associated with drug use, including alcohol,
caffeine, and benzodiazepines (which are often prescribed to treat anxiety).

Neuroanatomy

Neural circuitry involving the amygdala (which regulates emotions like anxiety and fear,
stimulating the HPA Axis and sympathetic nervous system) and hippocampus (which is
implicated in emotional memory along with the amygdala) is thought to underlie anxiety.[60]
People who have anxiety tend to show high activity in response to emotional stimuli in the
amygdala.[61] Some writers believe that excessive anxiety can lead to an overpotentiation of
the limbic system (which includes the amygdala and nucleus accumbens), giving increased
future anxiety, but this does not appear to have been proven.[62][63]

Research upon adolescents who as infants had been highly apprehensive, vigilant, and fearful
finds that their nucleus accumbens is more sensitive than that in other people when deciding
to make an action that determined whether they received a reward.[64] This suggests a link
between circuits responsible for fear and also reward in anxious people. As researchers note,
"a sense of 'responsibility', or self-agency, in a context of uncertainty (probabilistic outcomes)
drives the neural system underlying appetitive motivation (i.e., nucleus accumbens) more
strongly in temperamentally inhibited than noninhibited adolescents".[64]

The gut-brain axis

The microbes of the gut can connect with the brain to affect anxiety. There are various
pathways along which this communication can take place. One is through the major
neurotransmitters.[65] The gut microbes such as Bifidobacterium and Bacillus produce the
neurotransmitters GABA and dopamine, respectively.[66] The neurotransmitters signal to the
nervous system of the gastrointestinal tract, and those signals will be carried to the brain
through the vagus nerve or the spinal system.[65][66][67] This is demonstrated by the fact that
altering the microbiome has shown anxiety- and depression-reducing effects in mice, but not
in subjects without vagus nerves.[68]

Another key pathway is the HPA axis, as mentioned above.[67] The microbes can control the
levels of cytokines in the body, and altering cytokine levels creates direct effects on areas of
the brain such as the hypothalmus, the area that triggers HPA axis activity. The HPA axis
regulates production of cortisol, a hormone that takes part in the body's stress response.[67]
When HPA activity spikes, cortisol levels increase, processing and reducing anxiety in
stressful situations. These pathways, as well as the specific effects of individual taxa of
microbes, are not yet completely clear, but the communication between the gut microbiome
and the brain is undeniable, as is the ability of these pathways to alter anxiety levels.

With this communication comes the potential to treat anxiety. Prebiotics and probiotics have
been shown to reduced anxiety. For example, experiments in which mice were given fructo-
and galacto-oligosaccharide prebiotics[69] and Lactobacillus probiotics[68] have both
demonstrated a capability to reduce anxiety. In humans, results are not as concrete, but
promising.[70][71]

Genetics

Genetics and family history (e.g. parental anxiety) may put an individual at increased risk of
an anxiety disorder, but generally external stimuli will trigger its onset or exacerbation.[57]
Estimates of genetic influence on anxiety, based on studies of twins, range from 25–40%
depending on the specific type and age-group under study. For example, genetic differences
account for about 43% of variance in panic disorder and 28% in generalized anxiety
disorder.[citation needed] Longitudinal twin studies have shown the moderate stability of anxiety
from childhood through to adulthood is mainly influenced by stability in genetic
influence.[72][73] When investigating how anxiety is passed on from parents to children, it is
important to account for sharing of genes as well as environments, for example using the
intergenerational children-of-twins design.[74]

Many studies in the past used a candidate gene approach to test whether single genes were
associated with anxiety. These investigations were based on hypotheses about how certain
known genes influence neurotransmitters (such as serotonin and norepinephrine) and
hormones (such as cortisol) that are implicated in anxiety. None of these findings are well
replicated,[citation needed] with the possible exception of TMEM132D, COMT and MAO-A.[75]
The epigenetic signature of BDNF, a gene that codes for a protein called brain derived
neurotrophic factor that is found in the brain, has also been associated with anxiety and
specific patterns of neural activity.[citation needed] and a receptor gene for BDNF called NTRK2
was associated with anxiety in a large genome-wide investigation.[76] The reason that most
candidate gene findings have not replicated is that anxiety is a complex trait that is influenced
by many genomic variants, each of which has a small effect on its own. Increasingly, studies
of anxiety are using a hypothesis-free approach to look for parts of the genome that are
implicated in anxiety using big enough samples to find associations with variants that have
small effects. The largest explorations of the common genetic architecture of anxiety have
been facilitated by the UK Biobank, the ANGST consortium and the CRC Fear, Anxiety and
Anxiety Disorders.[76][77][78]

Medical conditions

Many medical conditions can cause anxiety. This includes conditions that affect the ability to
breathe, like COPD and asthma, and the difficulty in breathing that often occurs near
death.[79][80][81] Conditions that cause abdominal pain or chest pain can cause anxiety and may
in some cases be a somatization of anxiety;[82][83] the same is true for some sexual
dysfunctions.[84][85] Conditions that affect the face or the skin can cause social anxiety
especially among adolescents,[86] and developmental disabilities often lead to social anxiety
for children as well.[87] Life-threatening conditions like cancer also cause anxiety.[88]

Furthermore, certain organic diseases may present with anxiety or symptoms that mimic
anxiety.[15][89] These disorders include certain endocrine diseases (hypo- and hyperthyroidism,
hyperprolactinemia),[89][90] metabolic disorders (diabetes),[89][91][92] deficiency states (low
levels of vitamin D, B2, B12, folic acid),[89] gastrointestinal diseases (celiac disease, non-
celiac gluten sensitivity, inflammatory bowel disease),[93][94][95] heart diseases, blood diseases
(anemia),[89] cerebral vascular accidents (transient ischemic attack, stroke),[89] and brain
degenerative diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's
disease), among others.[89][96][97][98]

Substance-induced

Several drugs can cause or worsen anxiety, whether in intoxication, withdrawal or as side
effect. These include alcohol, tobacco, cannabis, sedatives (including prescription
benzodiazepines), opioids (including prescription pain killers and illicit drugs like heroin),
stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants.[99]
While many often report self-medicating anxiety with these substances, improvements in
anxiety from drugs are usually short-lived (with worsening of anxiety in the long term,
sometimes with acute anxiety as soon as the drug effects wear off) and tend to be exaggerated.
Acute exposure to toxic levels of benzene may cause euphoria, anxiety, and irritability lasting
up to 2 weeks after the exposure.[100]

Psychological

Poor coping skills (e.g., rigidity/inflexible problem solving, denial, avoidance, impulsivity,
extreme self-expectation, negative thoughts, affective instability, and inability to focus on
problems) are associated with anxiety. Anxiety is also linked and perpetuated by the person's
own pessimistic outcome expectancy and how they cope with feedback negativity.[101]
Temperament (e.g., neuroticism)[41] and attitudes (e.g. pessimism) have been found to be risk
factors for anxiety.[99][102]
Cognitive distortions such as overgeneralizing, catastrophizing, mind reading, emotional
reasoning, binocular trick, and mental filter can result in anxiety. For example, an
overgeneralized belief that something bad "always" happens may lead someone to have
excessive fears of even minimally risky situations and to avoid benign social situations due to
anticipatory anxiety of embarrassment. In addition, those who have high anxiety can also
create future stressful life events.[103] Together, these findings suggest that anxious thoughts
can lead to anticipatory anxiety as well as stressful events, which in turn cause more anxiety.
Such unhealthy thoughts can be targets for successful treatment with cognitive therapy.

Psychodynamic theory posits that anxiety is often the result of opposing unconscious wishes
or fears that manifest via maladaptive defense mechanisms (such as suppression, repression,
anticipation, regression, somatization, passive aggression, dissociation) that develop to adapt
to problems with early objects (e.g., caregivers) and empathic failures in childhood. For
example, persistent parental discouragement of anger may result in repression/suppression of
angry feelings which manifests as gastrointestinal distress (somatization) when provoked by
another while the anger remains unconscious and outside the individual's awareness. Such
conflicts can be targets for successful treatment with psychodynamic therapy. While
psychodynamic therapy tends to explore the underlying roots of anxiety, cognitive behavioral
therapy has also been shown to be a successful treatment for anxiety by altering irrational
thoughts and unwanted behaviors.

Evolutionary psychology

An evolutionary psychology explanation is that increased anxiety serves the purpose of

increased vigilance regarding potential threats in the environment as well as increased
tendency to take proactive actions regarding such possible threats. This may cause false
positive reactions but an individual suffering from anxiety may also avoid real threats. This
may explain why anxious people are less likely to die due to accidents.[104]

When people are confronted with unpleasant and potentially harmful stimuli such as foul
odors or tastes, PET-scans show increased blood flow in the amygdala.[105][106] In these
studies, the participants also reported moderate anxiety. This might indicate that anxiety is a
protective mechanism designed to prevent the organism from engaging in potentially harmful
behaviors.

Social

Social risk factors for anxiety include a history of trauma (e.g., physical, sexual or emotional
abuse or assault), bullying, early life experiences and parenting factors (e.g., rejection, lack of
warmth, high hostility, harsh discipline, high parental negative affect, anxious childrearing,
modelling of dysfunctional and drug-abusing behaviour, discouragement of emotions, poor
socialization, poor attachment, and child abuse and neglect), cultural factors (e.g., stoic
families/cultures, persecuted minorities including the disabled), and socioeconomics (e.g.,
uneducated, unemployed, impoverished although developed countries have higher rates of
anxiety disorders than developing countries).[99][107] A 2019 comprehensive systematic review
of over 50 studies showed that food insecurity in the United States is strongly associated with
depression, anxiety, and sleep disorders.[108] Food-insecure individuals had an almost 3 fold
risk increase of testing positive for anxiety when compared to food-secure individuals.
Gender socialization

Contextual factors that are thought to contribute to anxiety include gender socialization and
learning experiences. In particular, learning mastery (the degree to which people perceive
their lives to be under their own control) and instrumentality, which includes such traits as
self-confidence, self-efficacy, independence, and competitiveness fully mediate the relation
between gender and anxiety. That is, though gender differences in anxiety exist, with higher
levels of anxiety in women compared to men, gender socialization and learning mastery
explain these gender differences.[109][medical citation needed]

Treatment
See also: Fear § Management

The first step in the management of a person with anxiety symptoms involves evaluating the
possible presence of an underlying medical cause, whose recognition is essential in order to
decide the correct treatment.[15][89] Anxiety symptoms may mask an organic disease, or appear
associated with or as a result of a medical disorder.[15][89][110][16]

Cognitive behavioral therapy (CBT) is effective for anxiety disorders and is a first line
treatment.[111][112][113][114][115] CBT appears to be equally effective when carried out via the
internet.[115] While evidence for mental health apps is promising, it is preliminary.[116]

Psychopharmacological treatment can be used in parallel to CBT or can be used alone. As a

general rule, most anxiety disorders respond well to first-line agents. First-line drugs are the
selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.
Benzodiazepines are not recommended for routine use. Other treatment options include
pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others.[117]