Are Worry and Anxiety Related?

What is the relationship between anxiety and worry?  Can an individual worry and not feel anxious?  Similarly, can an individual feel anxious but not worried?  The age-old debate of which came first…the chicken or the egg once again applies.  In today’s post, I will discuss anxiety, theories of anxiety’s relationship to worry, its physiological symptoms and its origins.  The next post will discuss treatment options.

WHAT IS WORRY?

Is worry merely a different name for anxiety?  Worry is an integral component of anxiety, although worry is a process that can exist in the absence of anxiety.  Let’s identify worry as a primarily mental (thinking) activity.  When an individual worries, their mind is preoccupied with fear or dread. Often thoughts have a prevailing theme of negativity - rehearsing the worse case scenarios. Worry can range from the nagging little voice inside your head to unrelenting obsessions that can neither be ignored nor quieted.  Depending upon the severity of the negative thoughts and the permanency of those thoughts (statements that begin with never or always) some level of physiological reaction frequently follows.  Ultimately the mind convinces the nervous system to prepare for battle.  This then triggers a fairly predictable sequence of autonomic physical symptoms that characterize anxiety (e.g., fear, racing heart, sweating & tingling sensations).  In this theoretical framework, anxiety is identified as the reactive symptoms an individual feels within their body in response to their mental state of worry.

An alternative theory suggests that when an individual feels a myriad of undesirable physical symptoms that seemingly “come out of the blue” they often question their origin (a mental process) and may begin to either hyper-focus on the severity of the physical sensations or obsess about an ultimately fatal outcome when these symptoms worsen. Worry is the mental process triggered by feeling anxious rather than the cause of the anxiousness. Ultimately when worry sets in the autonomic system prepares either to take flight or to fight.  Some individuals may then experience the very scary physical symptoms known as a panic attack.  Following this logic, a panic attack is an extreme physical manifestation of anxiety. Understand that an individual may feel both worried and anxious and not experience a panic attack.

What conclusions can we draw from this chicken or egg debate?  Both positions identify a relationship between the mental processes and the physical symptoms that define the term anxiety.  Anxiety is neither all bad nor is it always a diagnosable condition!  Historically it has served as an alerting and preparation mechanism to safeguard us from impending danger.  For anxiety to meet DSM-V diagnostic criteria symptoms must be frequent, extreme and a source of ongoing distress (at least six months).

SYMPTOMS

Many symptoms of anxiety can mimic those of a heart attack - if you experience them seek medical attention immediately! Anxiety can present as chest pain or tightness in the chest, numbness and/or tingling in the arms and/or legs, labored breathing (as if an elephant is sitting on your chest), racing heart, cold sweats, dizziness, chills, tightness in the throat, elevated blood pressure, ringing in the ears, restlessness and/or agitation, gastrointestinal distress and most frequently a profound sense of impending doom.

Remember that when we’re anxious our bodies are activated to either flee or fight. A great illustration of this phenomenon has been captured by many National Geographic documentaries that feature hunting behaviors of animals in the wild.  The predator (lion) stalks and takes chase after unsuspecting prey (gazelle).  The gazelle exhibits the flight mode, the lion the fight mode.  Our brains have not yet evolved beyond these basic primal responses!

Additional physical symptoms of anxiety may include a cluster of symptoms characterized by tension: feeling keyed up or on edge, irritability, muscle tension, fatigue and sleep impairment.  Sleep impairment may range from difficulty falling asleep to early awakening to unsatisfying sleep (sleeping but not feeling rested).  Cognitive symptoms of anxiety may often include a temporary inability to recall names, events and previously over-learned information (mind going blank). The best example of this phenomenon is test anxiety-despite knowing the topic, the test appears to be written in a foreign language because the student cannot remember anything.  When a person feels anxious, it can also seem that any attempt to learn or take in new information is impossible.  This is another example of the mind going blank.  Once the anxiety dissipates, cognitive abilities return to their normal level of functioning. In summary, while the symptoms of anxiety are specific to the individual, general themes involve cardiac-like symptoms, tension symptoms and cognitive symptoms. Now let’s look at who, what and where regarding anxiety.

ORIGINS

Recent statistics indicate as of 2011, anxiety surpassed depression as the primary complaint identified by patients to their general practitioner.  Historically, women have been twice as likely as men to present with symptoms of anxiety.  Recent literature also suggests that men may be closing this gap as anxiety becomes less stigmatized within the general population.  Anxiety appears to be more prevalent in developed countries and spreads across lifespans.  The differentiating factors are age-related concerns.  For example, children may exhibit anxiety regarding school concerns while adolescents may be more likely to report anxiety regarding dating, school and independence.  Adults may report anxiety regarding advanced education, professional growth, marriage, families and aging parents.  The elderly may exhibit anxiety regarding their declining health status, grief from significant losses and their own death. 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, cites “childhood adversities and parental overprotection” as risk factors for developing anxiety.  Also reported in this edition is that one-third of the risk of developing a diagnosable anxiety disorder may be related to genetic transmission.  This is roughly equivalent to the genetic factors associated with a diagnosis of major depression. The balance of the contributing influences may be related to personal temperament.  This means that certain individuals who are harm avoidant, behaviorally inhibited and display negative affect may be more susceptible to developing an anxiety disorder compared to individuals who are more comfortable with risk, are behaviorally extroverted and display positive affect.

CONCLUSION

As I stated earlier in this post, if you intermittently worry and feel anxious, that may simply be a reaction to specific life events and completely normal: life can be stressful!  To meet diagnostic criteria, symptoms must be extreme, chronic and incapacitating.  The presence of panic attacks, symptoms that necessitate frequent emergency room visits and symptoms that render an individual unable to maintain appropriate daily self-care and social relatedness are of significant concern to both behavioral health and primary care professionals. In these instances, after a thorough evaluation, a diagnosis of anxiety may be warranted.

Stay tuned for Part II where I will discuss treatment options.  Specifics regarding panic attacks will be discussed in a dedicated post on that topic.

Is Quantity More Important Than Quality?

Over the past decade, this question has elicited the most animated discussions among clients in my practice.  It mostly refers to time management, usually regarding primary relationships: children, parents (including in-laws) and spouses.  This post will explore the relationship of quality to quantity as well as pose questions that will assist you in uncovering your motivation as it relates to these choices.

For the sake of clarity, I will first describe the terms that form the basis of this discussion.  Quantity broadly refers to things that can be measured, whereas quality is more discreet and refers to a peculiar or essential element.  Time management refers to the ability of an individual to allot their personal resources in the form of energy and focus in their life.  For purposes of this discussion, I will make one important assumption: that the individuals who are struggling to balance quality and quantity are truly seeking what is in the best interest of their loved ones and not using quantity v. quality simply as a justification for selfishness. 

Children

The primary dilemma that I hear voiced in my practice by parents is how to maximize interactions with their children while engaging in demanding careers. An unfortunate reality is that in the lives of infants and especially toddlers their “firsts” (i.e. smiling, standing, crawling, walking) cannot be scheduled.  As most parents can attest, sometimes stepping into the next room can be too far away from the action, let alone across town!  Therefore, with these developmental stages, quantity seems to trump quality.  Parents have attempted to maximize quantity through job share opportunities, split shifts and telecommuting.  Video streaming has also been a way that some parents have been able to remain connected despite demanding careers.  Yet another option has been childcare delivered by family members. During these developmental stages consider that quantity is quality.

An interesting juxtaposition occurs as your child enters school.  As the child’s interests broaden their preferences may transition to quality time rather than sheer quantity with their parents.  The parental problem at this developmental stage is what constitutes quality time?  Is it the 10 to 15 minute commute to and from music lessons, dance or sports?  Is it observing from afar their child’s extra-curricular activities?  Or does quality time refer to time spent playing video games with them or supervising homework? 

Each family needs to define what constitutes quality interactions.  I would hope that the definition includes a movement away from activities that involve coaching, critiquing and/or instructing.  Focus more on activities that require interaction with each other – board games, walks, hikes and gardening.  This is also a good time to begin rituals like family dinner hours, dedicated times for quieting of electronic devices and pre-bedtime rituals.  Remember that even though children may be completely capable of reading to themselves, reading with their parent at bedtime often remains a significantly fond memory years later. 

With adolescence and emerging adults the potential for a complete role reversal with their child may occur.  It is often the parent who complains of little if any time spent with their child.  Parents may suffer from “separation anxiety” when their teen leaves the house because as parents they cannot assure their child’s safety.  It is also a pivotal time when guilt may be used by both parents and their children to leverage opportunities for quality time. 

Parents who have traditionally assuaged their own guilt about the quantity/quality debate during their child’s earlier years may now consciously ramp up these efforts because their child is more vocal.  If buying “things” or attempting to create quality time with extravagant getaways became an avenue from which to engage with your child, the tables may turn when they become teenagers.  The child who has become accustomed to this parental behavior may now raise the ante to capitalize on their parent’s feelings of guilt.  This may be an example of a ritual that began in the early years that became unhealthy.  Why not focus on getting to know your teen and allow them to know you beyond your parental role? For parents, it may stave off feelings associated with the impending doom of empty nest.

Parents and In-Laws

In my post  “When the Child Becomes the Parent,” I explained the fundamental shift that occurs as our parents decline with age.   As senior parents decline, they may project more emotional dependency upon their adult children.  They are at risk for increased loneliness and this often translates into depression and anxiety that in turn affects their physical health. This is especially true when they live alone. In this case, quantity rather than quality is once again preferred, especially if their memory has been affected.  It is more difficult for them to know whether you visited last month or yesterday because their sense of time often becomes impaired.

Active seniors however, may have established a satisfying social life prior to their decline.  A considerable number of my clients report feeling angry that their parent(s) “don’t have time for their family.” My suggestion would be to book your time with them!  Quality would be the primary goal at this life stage.

Spouses/Significant Others

Ideally, couples want to spend time together.  I believe that there is often an assumption about what constitutes quality time rather than a mutually agreed upon decision.  If one partner believes that co-habitating addresses both the quantity and quality dimensions while the other partner actually expects some undivided attention, this could become a recipe for disaster!  Risks of assuming that your partner adopts your viewpoint increases with years spent together.     

If your relationship pre-dates the era of electronic devices, I highly suggest you discover how your mate really feels about their usage while spending time together.  If you are familiar with the book The Five Love Languages, it is safe to assume that therein lays valuable insight into what defines quality to each partner. If you are interested in this topic but have yet to complete the surveys at the back of the book, follow this link: http://www.5lovelanguages.com.

SUMMARY

This discussion has suggested two important points regarding quality and quantity in significant relationships: (1) One size does not fit all and (2) Quantity and quality are interrelated.  Not only do our life stages dictate our needs and desires for time, energy and dedicated focus, our temperaments also serve as a barometer for need. Thus the nature of the relationship and the key people affected dictate which choice is most necessary.  Since relationships are constantly evolving, what may be relevant one year may not be entirely relevant five years from now.  The last and most important point is that quantity and quality are interrelated.  I propose that quality time is not dependent upon extensive planning or exciting activities, but rather a spontaneous shared moment whereby a precious memory is created. Most frequently it involves sharing simple pleasures (sunsets, star gazing, sunrises). A simple pleasure requires the gift of time to occur naturally. Your life will become exponentially richer when you create an opportunity for spontaneity.  This requires chunks of non-dedicated time not only to experience simple pleasures but also share them with your cherished loved ones!