Oct. 1, 2018
Can a little anxiety be good for you? A look at different types of anxiety and what makes them disorders
You peel your tongue from the roof of your mouth and take a deep, juddering breath. Your pulse pounds in your temples. Sweat slicks your palms. You reach for the door knob and tell yourself, “Just open it. Don’t be ridiculous.” But the door swims and feints; your stomach flip-flops. No. You will not be attending the birthday party for Dave from Accounting today.
Anxiety lives and breathes in all of us; it’s a necessary part of our physiology — up to a point. A close cousin of fear, anxiety has protected us over the centuries, telling us to run from a crouching cougar or duck from a plunging spear. In the 21st century, fear has evolved; cougars and spears have become job loss, academic failure, and relationship conflict. These worries can be productive, motivating us to work hard and persevere. In some cases, sweaty palms and pounding pulses are rational responses. But a wide variety of Canadians have their own version of birthday-party fear. Anxiety is a shape-shifter, assuming many different forms and affecting diverse groups of people. It’s more common than you may realize.
The all-too-familiar feeling
According to the Centre for Addiction and Mental Health, as many as one in four adults will have an anxiety disorder sometime in their life, and one in 10 are likely to have had an anxiety disorder in the past year. For women, anxiety disorders are the most common mental health problem, and for men they are second only to substance abuse disorders. The Canadian Mental Health Association tells us that anxiety disorders are the most common illness in children and youth, affecting about six per cent at some point. Anxiety imposes itself on Canadians through a broad range of symptoms and intensity levels.
The shifting shape of anxiety
When the symptoms of anxiety begin to interfere with everyday life, it’s time to consider the possibility of an anxiety disorder. This mental illness takes myriad forms, from generalized anxiety disorder to social anxiety disorder to agoraphobia to panic disorder. Post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder are closely related to anxiety, too, although they have several distinguishing features.
Not surprisingly, the groups of people affected by anxiety disorders are varied, ranging from young children and university students to pregnant women and members of persecuted minorities.
To mitigate the effects of this wide-ranging mental illness, researchers at the University of Calgary are investigating its causes and risk factors. Their findings reveal anxiety disorders as complex and hard to pin down, their tendrils linking body and mind, emotion and intellect. And because anxiety disorders are so varied and complex, progress is gradual.
Anxiety schools the young
As a former school psychologist, Dr. Gabrielle Wilcox, PsyD, is all too familiar with anxiety in children. Now an associate professor of school and applied child psychology in UCalgary’s Werklund School of Education, Wilcox says that anxiety was the most common complaint for the young students she worked with. “It’s definitely a problem that parents and kids are wanting help with,” says Wilcox. “And since it’s been more prominent in the media, I think parents have a better understanding of the resources available to them.”
The increasing public exposure of mental illness issues is helping to create a less judgmental atmosphere, but Wilcox says there is still a long way to go toward destigmatization. Wilcox is part of a research team studying mental health stigma. This multidisciplinary group of investigators, based at the Mathison Centre for Mental Health Research & Education, part of the Cumming School of Medicine's Hotchkiss Brain Institute, is following a group of Grade 9 students over a one-year period. Using questionnaires and qualitative interviews, researchers hope to learn about the impact of anxiety and other mental health symptoms, as well as the effect of mental health stigma on school success.
The team works with two Rocky View schools to test a program called Headstrong, designed by the Mental Health Commission of Canada. The program helps reduce negative attitudes around mental illness, and the team hopes their study will lead to improvements in school-based mental health programs. “There is a big push in this direction,” says Wilcox. “Right now kids often don’t have access to the right resources and supports.”
Throwing a curve at anxiety
One way around the stigmatization of anxiety is realizing that anxiety is not inherently negative. “There’s a lot of research depicting a curvilinear response,” says Wilcox. “A little bit of anxiety is productive, but too much is counter-productive.”
Take the example of studying for a test. “If you don’t feel any anxiety about an exam, you may not feel motivated to prepare properly,” Wilcox says. But the other end of the curve is equally problematic. “For children with anxiety disorders, the worrying can inflate to the point of interfering with schoolwork,” she says. “That’s when parents and educators need to intervene.” It’s a matter of finding a happy medium. “If you have some anxiety about the test, you’ll work hard and do well.”
How to shift away from anxiety
One of the most effective treatments for anxiety disorders, says Wilcox, is cognitive behavioural therapy (CBT). She is most familiar with its applications for children, but it’s widely used for anxiety disorder patients of all ages. CBT is designed to modify dysfunctional thoughts, emotions and behaviours. It helps patients find concrete solutions to problems, and encourages them to change negative patterns of behaviour by recognizing and challenging thinking patterns that lead to a distorted view of a situation. “In schools you can also do group sessions to help students learn skills to manage thoughts and physiological responses, and help them feel calmer,” Wilcox says.
Wilcox has seen success with cognitive behavioural therapy, particularly for children who are so anxious about school that they refuse to attend. “We can ease them back by gradually exposing them to the things they’re anxious about,” she says. “We often combine that with learning coping strategies through CBT, and ultimately they’re back in school all day long.”
Nature vs. nurture
Anxiety disorders have definite genetic risk factors, but they're also linked to environmental factors like substance abuse, struggles with poverty or emotional trauma. Parents with anxiety are more likely to have anxious kids, according to Wilcox, but does that reveal a genetic or environmental link?
Both, says Wilcox. “Remember that the anxious parent may be overprotective, giving messages to kids that the world is a dangerous place,” she says. Wilcox uses the Diathesis-stress model to explain the overlap between biological and environmental factors: “This theory says that some people are biologically predisposed to anxiety, and if the right environmental factors are applied on top of your pre-existing vulnerability, you’re more likely to develop an anxiety disorder. So both genetics and environment can increase the odds.”
A deep dive into the gene pool
Unraveling the causes of anxiety disorders is a job requiring delicacy and precision. It’s a task faced by Dr. Paul Arnold, MD, PhD, an associate professor in the departments of Psychiatry and Medical Genetics at the Cumming School of Medicine, director of the Mathison Centre, and member of the Hotchkiss Brain Institute. Arnold explores the genetic and neurobiological underpinnings of childhood psychiatric disorders, and he is a practising psychiatrist, treating children with obsessive-compulsive disorder (OCD) and anxiety disorders.
Anxiety is a key symptom for those suffering from OCD. A person with OCD develops compulsions to reduce the anxiety caused by an obsession. For example, a child may be obsessed with the possibility of an intruder breaking into her home, so she compulsively checks the locks on doors and windows. She may realize that her behaviour doesn’t make sense, but may not be able to control it. On the surface, an obsession about security may not seem completely irrational. “Lots of people have obsessive thoughts or compulsive behaviours,” says Arnold, “But it’s the anxiety and distress that turns it into a disorder.”
Arnold is currently measuring the mental health of a large group of children from the general population, and investigating traits like anxiety and OCD. He’s interested in the genetic factors that may put these youths at risk, and has been collecting samples of their DNA. The goal is to develop a clearer picture of OCD and its biological roots. “The more genetic information you have, the better you can target treatment,” says Arnold.
Unspinning the tale of trauma
In addition to OCD, Arnold is interested in post-traumatic stress disorder and other mental health disorders resulting from trauma. Arnold plans to look at children who are at high risk for mental health disorders because they have experienced trauma such as abuse or maltreatment. He hopes to get a better understanding of how genetic and environmental risk factors combine to trigger mental illnesses. But he’s also looking for clues about genetic factors that protect children from mental illness.
“What’s amazing is that there are kids in the most horrible environments who come out relatively okay,” says Arnold. “So we’re wondering why they are so resilient relative to their peers. And some of that might be because of their genetic makeup.”
But it’s not just a matter of genetics when a child with a mental illness comes from an abusive home life, or experiences severe bullying. “It’s intuitive,” says Arnold. “Of course those environmental factors will put you at risk.” The question is, how does the combination of genetics and the environment produce a child with mental illness?
Variants upon variants
Initial assumptions around the genetic roots of mental health were misleading, according to Arnold. “The field started from a simplistic idea that there might be a smoking gun on genetic variance — if you have one single gene for something like anxiety, you’re at high risk. But no, it’s looking more complicated than that.”
The sheer complexity of the human genome and its myriad processes make genetic research seem formidable. “For any given person, you have to look across the whole genome and take into account thousands of variants,” says Arnold, “and then you have to look at their combined impact and figure out the risk that person is at for mental health disorders.” You also have to consider that genetic variations are not always the bearers of bad news where mental illness is concerned; they can also reduce the risk for some disorders.
Add to that intricate relationship between genetics and the environment, and you have a tangled web indeed. Researchers like Arnold are turning to a new research area, called epigenetics, to untangle the associations between environmental and genetic factors contributing to mental illness.
Since when are genes so flexible?
The study of epigenetics involves looking at the genome as a dynamic locale. Researchers find that as a human grows and develops, intricate chemical reactions activate and deactivate genes.
“Epigenetics looks at changes in the structure of your genome or the way your genome is expressed – and these are things that change depending on your environment,” says Arnold. It’s a sort of meeting of the minds between nature and nurture theories. Researchers are now considering how genetic factors change over time, and what impact they’ll have on individuals over the long term. And the environmental factors that interact with genes include the various interventions that health practitioners suggest for patients. With new fields such as epigenetics opening up, health practitioners may find anxiety disorders easier to understand and treat.
Asked what the future holds for the study of childhood anxiety disorders, Arnold responds with cautious optimism. “It will take time for findings to translate into health benefits,” he says. “But researching the underpinnings of childhood mental illnesses should help us identify risk factors and target treatments.”
Practitioners might be able to pinpoint kids who are at an increased genetic risk and then treat them in a preventative way, for example. Or identify kids who would benefit from certain medications, and what side effects they might have. “We could eliminate some of the trial-and-error side of our current methods,” says Arnold, “and that gets us closer to the goal of precision medicine.”
Anxiety of the future
What would a mental health appointment look like in the future, once current research shines more light on anxiety disorders? Here’s one possible scenario:
It’s 2038 — how is that possible? After so many years you still have the sensation of an iron band clamped around your ribs. You wash your hands, it’s time to leave for your appointment, but you scrub your hands again and again. Finally you feel ready. At your physician’s office, you listen as she discusses the genetic sequencing report she has on file. She goes over notes on your genome configuration and writes out a prescription. “It’s the best medication, given your particular combination of genetic and environmental risk and protective factors,” she tells you. She’s been able to diagnose you precisely, and target your treatment based on your genomic profile. “You should have success with cognitive behavioural therapy,” she says, “combined with a particular type of medication, and some exposure therapy.” You thank her and head back to work. There’s something about having concrete steps in place that makes the iron band seem looser, lighter. It’s easier to breathe.
Changing the future for pregnant women and new mothers
The delicate dance performed by genetics and environmental factors takes centre stage in the study of perinatal anxiety. Just ask Dr. Dawn Kingston, RN, PhD, associate professor in UCalgary's Faculty of Nursing, the Lois Hole Hospital for Women Cross-provincial Chair in Perinatal Mental Health, and a member of the Mathison Centre for Mental Health Education & Research.
Kingston’s research centres on improving perinatal mental health — that of pregnant women and new mothers. One in four pregnant women experiences anxiety in pregnancy or post-partum. “Women with anxiety tend to worry about things that didn’t cause them to worry before,” says Kingston. “It’s often a relentless and persistent feeling, and it can turn into a panic attack, where your heart is racing, you’re sweating and you feel extremely unwell.”
Kingston encourages women to seek support for mental illnesses and she dispels some of the misconceptions around perinatal anxiety.
“Most people see postpartum depression as the iconic mental illness for these women,” says Kingston. “But in reality, anxiety — in pregnancy and after delivery — is at least as pervasive.” She also notes that the biggest risk factors for developing perinatal anxiety are problems with your partner, low social support, previous mental health problems, and high stress. “Thus busting the myth that perinatal mental health problems are all about hormones,” says Kingston.
Another surprising fact, according to Kingston, is that 30 to 40 per cent of women suffering from perinatal anxiety will continue to experience anxiety several years after pregnancy. “Many experienced it before they began having children,” she says. “It’s often an ongoing issue, not an isolated one.”
The anxiety cycle
Perinatal anxiety may not always be a new problem, but it’s particularly important to deal with it. “It’s crucial to manage anxiety at this time of life,” says Kingston. “If we don’t manage it during pregnancy it sets up a cycle that impacts the whole family.” Research shows that women who experience perinatal anxiety tend to have anxious children. And those children go on to become anxious adolescents, and anxious adults. It’s not clear exactly how much of this intergenerational process is due to genetics, and how much is due to their environments.
What is clear, though, is that the link between maternal and childhood anxiety places an onerous responsibility on expectant mothers. Kingston has no wish to add guilt and fear to the already challenging process of pregnancy. “It’s not an easy subject to raise with pregnant women,” she says. “There are already so many physical and emotional changes to contend with.” But she advocates for taking the stigma out of anxiety. “You gather the facts and you simply deal with it. It’s part of life — like managing diabetes.”
Unfortunately, women often don’t feel this sort of clarity around whether their anxiety is normal or not during pregnancy. And women who feel confused about their mental health symptoms don’t tend to seek professional support. “Women want to be ‘good’ patients, and they know they have that five minutes with their obstetrician, so they don’t want to waste their time,” says Kingston. “That leads to a cycle of non-disclosure and non-detection.”
E-solutions to perinatal anxiety
Part of what makes the invisibility of perinatal anxiety so tragic is that it is highly treatable. Kingston encourages women to discuss options like medication and therapy with their physicians. Options such as cognitive behavioural therapy (CBT) can be highly effective for perinatal anxiety.
But because women tend to hesitate to seek professional help, and because Canada has no formal screening system for perinatal anxiety, Kingston is advocating for a routine screening program for anxiety. She and her research team have come up with a practical solution to the invisibility of maternal anxiety: they've developed a digital platform, called HOPE, to support perinatal mental health. Launching in October 2018, the HOPE platform offers e-screening, e-referral, and e-therapy as well as evidence-based information on perinatal mental health for women and health-care providers. It also provides treatment options such as online coaching for pregnant women and new mothers suffering from anxiety.
Survival of the most anxious?
If anxiety performs a useful role in human evolution, what reason might there be for anxious mothers producing anxious children? Kingston cites the work of Vivette Glover, professor of perinatal psychobiology at Imperial College in London, UK, to answer this question. In an article on prenatal stress, Glover suggests that passing on anxiety from mother to child could help future generations adapt to demanding conditions in the world at large. “Anxiety may have been associated with increased vigilance,” says Glover. Kingston adds that handing anxiety down to children “prepares them for an adverse world, giving them that fight-or-flight instinct, and making them reactive to the point that they are better able to look after themselves in difficult circumstances.”
The social side of anxiety
If you had to pick the thorniest aspect of 21st century life you might choose financial uncertainty, job loss due to artificial intelligence, or identity politics. But for people with social anxiety disorder (SAD), today’s thorns are prickliest when people stand cheek to jowl with other people. Friends, family, colleagues and peers — they all radiate varying levels of stress. Dr. Kathleen Hughes, PhD, an instructor in the Department of Psychology, studies SAD, particularly as it relates to children and young adults.
Hughes defines social anxiety as a preoccupation with what other people think of you. “You’re always focused on others’ opinions, even if it’s completely unwarranted,” she says. Whereas generalized anxiety disorder is linked with a sense of worry, SAD sufferers tend to be preoccupied with negative evaluation, or being judged in a negative way. They tend to avoid stressful situations, internalize their emotions, and feel poorly about themselves.
Social anxiety on campus
One of Hughes’s current research projects focuses on university students who experience social anxiety. “Which is not unusual when you’re transitioning into a new environment with lots of social changes,” she says.
Like other forms of anxiety, SAD exists on a spectrum. “Worrying about what other students and professors think about you is normal for the first month or so,” says Hughes. “We’re looking at students with high anxiety who disengage with campus life. They don’t feel connected and tend to think others don’t like or respect them.”
Hughes’s research delves into coping mechanisms for university students with SAD. “Although there are good ways to treat anxiety, like cognitive behavioural therapy (CBT), mindfulness, and relaxation, there will always be some level of anxiety for these students; it’s not going away completely,” says Hughes. Her study investigates the social emotional competencies, or positive traits, that can be nourished in students to help them manage their social anxiety and engage with university life. The traits that may counter anxiety include assertiveness, empathy and compassion, optimism, humility and self-awareness.
On a more general level, troubling results from the 2013 National College Assessment Survey showed students were coping with depression, loneliness and other types of anxiety in addition to social anxiety. These findings led to the development of UCalgary's Campus Mental Health Strategy in 2015, to address concerns across campus about mental health and well-being.
Social anxiety at university: what does it look like?
Social anxiety disorder plays out in fairly particular ways when young people are surrounded by peers in classrooms, quads and cafes. Here are some behaviours that typify this experience for young people with SAD:
- Trouble making friends
- Persistently worrying about what other students and professors think about them
- Avoiding stressful situations like discussion-based classes — dropping classes that look too demanding socially
- Avoiding speaking in class
- Dreading presenting in front of the class
- Dreading being evaluated in front of peers — e.g. being told an answer is wrong when they speak out in class
- Preferring individual work to group work
- Wishing to be social but not knowing how
- Hovering around social peers instead of taking part
These concrete signs of anxiety can be unproductive and stressful. They might make you wonder what role anxiety plays in humanity’s march toward the future.
Why social anxiety? The evolutionary perspective
Evolutionary psychologists believe that humans had important reasons for being extroverted and concerned with others’ opinions. “When we were hunters and gatherers, living in tribes vulnerable to the elements of nature, we needed the protection of kinsmen,” says Hughes. “One way to ensure your status in a community was to be concerned about others, to be empathetic with your peers, and even to be embarrassed about something you did that offended the larger group.” This kind of social anxiety was productive and allowed humans to thrive.
The LGBTQ university experience: an anxiety riddle
Many people today manage to thrive even as they experience anxiety. One of the university demographics that Hughes is particularly interested in is the LGBTQ community. She is running a second research project exploring the resiliency of LGBTQ students who suffer from high social anxiety.
“The early results are quite extraordinary,” says Hughes. The students who identify as LGBTQ have similar levels of student engagement as those who don't. “But the LGBTQ group has much higher levels of social anxiety,” she says. “They’re just as engaged as students without social anxiety, but they are still experiencing the stress of SAD.”
Students in persecuted minority groups have good reason to be anxious, says Hughes. “They’re bound to be preoccupied with their gender or sexuality issues — they see them in the headlines and on social media; it’s a hot topic of conversation and it’s inescapable. This feeds their anxiety.”
But the students in the study don't act like students with SAD. “Even though they have high anxiety, they don’t avoid going to class and don’t seem overtly nervous,” says Hughes. “They actually seem very engaged in school.”
So why do these LGBTQ students buck the trends of social anxiety? “I suspect that those who make it to postsecondary education are the people who have learned to persevere and have become resilient enough to get to university,” says Hughes. Her theory recalls Paul Arnold’s study of children with OCD and backgrounds with trauma — Arnold, too, found amazing levels of resiliency in some young people.
In addition to the resiliency factor, Hughes wants to explore other elements contributing to the staying power of these students. “Are there other traits that help them overcome anxiety? Or is it really down to resilience?” Resilience is tied to personality, says Hughes, so to a certain extent it’s something you’re hard-wired for. “You can measure an infant and see how long they’ll reach for a dangly toy,” says Hughes. “That measurement will predict later behaviour — like whether they’ll keep trying to get a certain job.”
As her research project unfolds, Hughes hopes to determine whether resiliency is the over-arching reason these LGBTQ students are so engaged at university, or whether there are other factors at play. “It’s fascinating,” says Hughes. “Because it’s all about what people can be taught, and what’s bred in the bone.”
The shape of anxiety to come
Mental illnesses like anxiety disorders will no doubt continue to challenge researchers like Wilcox, Arnold, Kingston and Hughes well into the future. The process of deciphering genetic and environmental risk factors is complex. But the shape of anxiety is gradually becoming more defined as scholars continue to investigate the myriad forms of anxiety disorders, and dive deeply into new areas like epigenetics.
Will anxiety disorders ever disappear from the human psyche? It’s difficult to say, but in the meantime, Kingston suggests keeping calm and carrying on. “It’s something we simply have to manage,” she says. “Like high blood pressure or diabetes. Take care of yourself and talk to your health-care provider. We’re here to help keep you emotionally healthy throughout your life.”
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ABOUT OUR EXPERTS
Dr. Gabrielle Wilcox, PsyD, is an associate professor of school and applied child psychology in UCalgary’s Werklund School of Education and a member of the Mathison Centre for Mental Health Education & Research. Her research focuses on improving our understanding of how to support student learning and preparation for post-school requirements. Specific areas of research include neuropsychology for intervention, mental health in schools, transition planning, and university-level instruction. Read more about Gabrielle
Dr. Paul Arnold, MD, PhD is an associate professor in the departments of Psychiatry and Medical Genetics at the Cumming School of Medicine, director of the Mathison Centre, and member of the Hotchkiss Brain Institute. His research focuses on the genetics and neurobiology of childhood obessesive-compulsive disorder (OCD) and related neuropsychiatric disorders. Paul is a child and adolescent psychiatrist with particular expertise in pediatric OCD. Read more about Paul
Dr. Dawn Kingston, RN, PhD, is an associate professor in UCalgary’s Faculty of Nursing, the Lois Hole Hospital for Women Cross-Provincial Chair in Perinatal Mental Health, and a member of the Mathison Centre. Dawn’s research focuses on improving perinatal mental health as one of the strongest, modifiable influences of child mental health and development. Read more about Dawn
Dr. Kathleen Hughes, PhD, is an instructor in the Department of Psychology in UCalgary's Faculty of Arts. Her research focuses on how students' social and emotional strengths can influence their educational experiences. Topics include socioemotional factors, demographic factors and educational outcomes. Read more about Kathleen