Mental Wellness: Anxiety - what is it?



Let me begin by telling you a little bit about me. I am an outgoing person; I am sociable; I love people and, when I'm well, I get energy from being around them (this makes me an extrovert). I am a happy person; optimistic and a believer in people being fundamentally good. I am trusting of others. 

I also have an anxiety disorder.


This series

Inspired by an excellent photography exhibition on anxiety and mental illness by Danielle Langham, over the next few posts, I would like to talk to you about anxiety. 

This post will discuss the main features of anxiety in terms of Psychology, Neurobiology, and Symptomatology (I could have just said 'symptoms' then, but I was enjoying the flow too much - I do love lexicology 😉). 


In upcoming posts, I will discuss my own experience of anxiety, secondary to Complex Post-Traumatic Stress Disorder (C-PTSD), and finally, I will give you tips on how to cope with, and reduce, your anxiety. This will be based on my own experiences of living with this condition.


Disclaimer: I am not a mental health professional or neurobiologist.


Spoiler: this series will have a happy ending for you.


Anxiety - you've all heard of it, but what is it?


Like most mental health disorders, the term 'anxiety' is overused and generalised to a point where, sadly, many people who think they know what it means to be anxious, don't actually understand the seriousness of the condition. Therefore by continuing to misuse the term, the stigma and ignorance around anxiety increases.

This can leave people who really do have an anxiety disorder to feel that their very real experience of anxiety isn't valid, or that they are coping with their own anxiety less well than other people, who, it turns out, don't actually have the disorder. Hardly a fair comparison. 


This stigma and misunderstanding can lead to people who are experiencing anxiety to be harder on themselves, less willing to talk about the seriousness of their condition with others and, therefore, more prone to becoming unwell in silence.



                                                                      © Danielle Langham Photography



Anxiety disorders are marked by excessive fear (and avoidancein the absence of true danger, often in response to specific objects or situations (Shin & Liberzon, 2010). The  International Classification for Diseases (ICD-10, 2018) describes anxiety disorders as:

  • A category of psychiatric disorders which are characterised by anxious feelings or fear often accompanied by physical symptoms associated with anxiety.
  • A disorder characterised by apprehension of danger and dread accompanied by restlessness, tension, tachycardia (racing heartbeat), and dyspnea (shortness of breath) unattached to a clearly identifiable stimulus.
  • Disorders characterised by anxiety or dread without apparent object or cause. Symptoms include irritability, anxious expectations, pangs of conscience, anxiety attacks, or phobias
The Diagnostic and Statistical Manual of Mental Disorders, or DSM-V*, (*read 'Psychiatry Bible') explains that anxiety disorders "share features of excessive fear and anxiety and related behavioural disturbances".


Fear is "the emotional response to a real or perceived imminent threat" 

whereas 

Anxiety is "anticipation of future threat"

The two states are different but they are linked and can overlap. 

Fear is involved mostly with increased autonomic arousal (our 'fight-flight-freeze response'), whilst anxiety is more associated with cautious and avoidant behaviours (DSM-V).

How Common is it?

Anxiety, which can be 'persisting and disabling' (ICD-10), is the most common of all mental disorders. It affects about 1 in 13 people (7.4%) with global prevalence varying from, on average, 5.3% in African cultures to 10.4  in Euro-Anglo cultures (Baxter et al., 2013). Approximately just over 1 in 4 people will experience some form of anxiety disorder in their lifetime (Kessler et al., 2005).


What's happening in the brain when I am anxious?


See this 2015 systematic review for an excellent, but extremely detailed, review of what we  understand so far about of neural circuitry in anxiety and related disorders.
Here are the basics:
                                                                                                                                                                                          © Danielle Langham Photography



The cerebral cortex (the 'thinking' centre)


The cortex forms the outside of the brain; it is the deeply folded, sausage-like part of the brain which you will be familiar with from pictures. Sensory pathways for vision, touch, hearing, taste and smell identify information about objects and events from the outside world, they then travel through the cortex (the thinking centre) and send this information on to the hippocampus.


The hippocampus (memory centre)


The hippocampus, Latin for 'seahorse', is a seahorse-shaped structure which lies deep within the centre of the brain; we have one in both of our two hemispheres in the brain, and these areas are where our memories are stored. Think about when you were in school and you put your hand up in class. You just activated your hippocampus, well done!

The circuit between the sensory pathways from the cerebral cortex and the hippocampus allows for the following: 


You're wandering around in a jungle when you see and recognise a huge rock next to a river, you suddenly remember that the last time you saw that rock, and heard that river, a lion tried to attack you! A useful memory in order to survive, eh? However, this memory by itself would be useless if, for example, all you did after remembering the scene was to go on to sing "in the jungle" at the top of your lungs whilst waving around a couple of raw steaks!

The memory alone is helpful but it doesn't help us if we don't know what to do with that information: we need it to activate an 'alarm' to alert us when to use this information and to get our bodies prepared for the possibility of danger so that we can survive.


Very recently, in February 2018, an article was published in Neuron which describes how 'anxiety cells' have been identified at the bottom of the hippocampus in mice. These cells fire off in situations which are possibly threatening and which are associated with a previously formed negative memory. These cells then communicate with the Amygdala.


The Amygdala (emotional centre for fear, anxiety and disgust)


The role of the amygdala is to attach emotional significance to objects, people and situations, to respond to emotional stimuli and to form emotional memories. It is there to protect us - it just gets a bit carried away at times.


The amygdala is a small almond, shaped structure in the brain (we have one in both hemispheres). It can be accessed via two routes

The first is through the route above, in which sensory information travels through the cortex, the hippocampus and then the amygdala. This means that, using the examples above, not only do you recognise the landmark in the jungle, and remember that Rory tried to have you for his lunch last July; because of the amygdala flashing setting off the alarm, you also know to be on high alert and get ready to respond accordingly (my advice is, run!)

The amygdala can also be accessed  more directly from the cortical sensory pathways. This second route means that the hypothalamic 'memory centre' is now bypassed to allow for automatic, unconscious processing of emotional and social stimuli (Pessoa & Adolphs, 2011). Essential if you need to respond extremely quickly to danger.

Although it sounds like the information travels one way, most of these pathways go both ways; so the hippocampus can store a memory and communicate this with the amygdala, creating an emotional response, and the amygdala can create an emotional memory and associate this emotion with the memory inside the hippocampus. 

Anxiety occurs when the amygdala fires off without needing to due to a miscommunication in the bidirectional pathways between the cortex and the amygdala, or, the hippocampus and the amygdala. Basically, we should blame the bloody amygdala! But, let us not be too harsh, like I said, it's just trying to protect us. 

This miscommunication can occur because of a combination of nature (your genetics) and nurture (your environment). 

In C-PTSD, where people are exposed to sustained abuse or situations from which they feel they can't escape for a long time, usually as children but not always, the hippocampus appears to be bypassed when it shouldn't be and amygdala is often over-activated resulting in emotional memories, and 'emotional flashbacks' when the person is actually safe from harm.

A case for the amygdala



Let us take a quick trip to Mauritius to discuss dodos. Why not? 



These unassuming creatures have reached simile-level-status of extinction, and for good reason. For about a million years, this flightless bird evolved on an island where it had no threat to itself or its eggs from other predators. It therefore had no reason to feel fear. It was not stupid, you understand. Nor brave (I can't imagine one can be brave without having to overcome fear - raises eyebrows and nods head knowingly towards you). No, it just had no memories of ever being threatened. Nor, it appears, did it have a system to alert itself to the possibility of new threat. Cue humans arriving and the Dodo wandering up to them curiously. 

                    Sadly, the rest is history. 

So, after that happy anecdote, I hope you see that both anxiety and fear, and an alert amygdala, are essential evolutionary traits from the days gone by in order for humans to survive. It allowed our ancestors to be vigilant of and fight, or escape from potential threats when needed. 

Today, fear and anxiety remains useful in times when we are threatened e.g. from situations which are dangerous, including trauma. But, as many people will tell you it does not take a tiger to experience the intense feelings of being threatened - it could take a presentation; an interview; a date; a bus journey; leaving the bed. 

This is anxiety.

Symptoms of Anxiety


Anxiety affects everyone in different ways, it is often associated with excessive worrying, although this is not something I tend to associate with it. For me it is usually a highly physical experience and I have to work hard to understand why I am feeling anxious - this is because my amygdala is responding more quickly and setting off the 'fear alarm' and my body is responding to this alarm more quickly than my memories and thoughts are activated.


                                                                                                                                                                              © Danielle Langham Photography


Once the amygdala raises the alarm, it evokes the fight-flight-freeze reflex by triggering the release of stress hormones such as cortisol and adrenaline within the body. These hormones are designed to increase heart rate, reflexes and speed. and for blood to be diverted away from our extremities and digestive system towards the major muscle groups. Because of this, symptoms can include:

  • Racing heart
  • Palpitations
  • Shortness of breath
  • Dizziness
  • Stomach cramps
  • Going to the toilet more, or less often
  • Sweating
  • Nausea
  • Sickness
  • Impending sense of dread or fear
  • Inability to go to sleep
  • Inability to stay asleep
  • Nightmares
  • Grinding teeth (especially at night)
  • Inability to feel calm or relaxed
  • Dry mouth
  • Cold, sweaty, numb or tingling hands and/or feet
  • Muscle tension
  • Repeated thoughts or flashbacks (including purely emotional) to traumatic experiences
  • Changes in sex drive
  • Changes in eating habits
  • Headaches
  • Panic attacks
  • Other somatic symptoms including aches and pains


Hopefully, this post has given you some further understanding of what anxiety is and how it can present in a person. It explains that anxiety occurs at a neurobiological and psychological level, affecting a person's physiological responses and behaviours. Anxiety occurs as a result of a person's genetics as well as their environment and experiences. It affects everybody in different ways. My next post will talk about how anxiety has affected me, personally. My final post will be on ways to cope with anxiety.

If anybody would like to get in touch with me through twitter @mentalwellness6 about their own experiences of anxiety, their thoughts around this topic and/or tips to help others, I would be very happy to hear from you.


References


Baxter, AJ., Scott, KM., Vos, T. & Whiteford, HA. (2013).  Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine, doi:10.1017/S003329171200147X


ICD-10. (2019). Anxiety Disorders Unspecified.  http://www.icd10data.com/ICD10CM/Codes/F01-F99/F40-F48/F41-/F41.9 


Jimenez, JC., Su, K., Goldberg, AR., Luna, VM., Biane, JS., Ordek, G., Zhou, et al., (2018). Anxiety Cells in a Hippocampal-Hypothalamic Circuit. Neuron, 97(3), pp 670-683 http://www.cell.com/neuron/fulltext/S0896-6273(18)30019-9 


Kessler, RC., Berglund, P., Demler, O., Jin, R., Merikangas, KR. & Walters, EE. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62:593–602. 

Langham, D. (2018). One Breath. Danielle Langham Photography [website] www.DanielleLangham.co.uk/onebreath

Pessoa, L. & Adolphs, R. (2011). Emotion processing and the amygdala: from a ‘low road’ to ‘many roads’ of evaluating biological significance. Nat Rev Neurosci, 11(11): pp 773–783. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025529/ 

Preston, AR. & Eichenbaum, H. (2013). Interplay of hippocampus and prefrontal cortex in memory. Current Biology, 23(17), pp 764-773  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789138/

Comments

  1. i think it’s super important to find posts like this, where you’re opening up and being honest. love it thank you!!

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