Week 10: The Anxious Brain
Recording
If you missed the class or if you would like to hear the lesson, here is Dr. Minoo delivering a synopsis of this lesson.
Video:
Our Wednesday night class enjoyed this 5 minute guided meditation to relieve anxiety. Try it!
The Anxious Brain
We all experience anxiety. For example, driving in heavy traffic is a common source of anxiety, but it helps keep us alert and cautious to avoid accidents. In fact, anxiety is a normal reaction to stress. Mild levels of anxiety can be beneficial in some situations. It can alert us to dangers and help us prepare and pay attention. However, when feelings of intense fear and distress become overwhelming and prevent us from doing everyday activities, it may be anxiety disorder. This week we will look at what is happening in an anxious brain, how anxiety affects different aspects of life, signs and causes of an anxious brain, and how to rewire an anxious brain.
May 20th is National Older Adult Mental Health Awareness Day. The National Council on Aging (NCOA) is working to remove barriers to understanding anxiety disorders. There is a free virtual event on Thursday, May 2nd 2024 for the 7th Annual Older Adult Mental Health Awareness Day (OAMHAD). If you are interested, registration is open. (National Council on Aging, 2024)
What is Anxiety Disorder?
Feeling anxious or nervous is a common emotion for people of all ages and a normal reaction to stress. Feeling anxious can help us handle problems and strange situations, and even avoid danger. It is normal to feel anxious about illnesses, new social interactions, and frightening events. But when one feels anxious often and the anxiety is overwhelming and affects daily tasks, social life and relationships, anxiety disorder may be the cause. (American Association for Geriatric Psychiatry, 2022). In other words, anxiety disorder can cause significant impairments in important areas of our lives such as work, school, relationships, and reduce quality of life. In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must:
● Be out of proportion to the situation or be age-inappropriate
● Hinder their ability to function normally
Feeling anxious or nervous is a common emotion for people of all ages and a normal reaction to stress. Feeling anxious can help us handle problems and strange situations, and even avoid danger. It is normal to feel anxious about illnesses, new social interactions, and frightening events. But when one feels anxious often and the anxiety is overwhelming and affects daily tasks, social life and relationships, anxiety disorder may be the cause. (American Association for Geriatric Psychiatry, 2022). In other words, anxiety disorder can cause significant impairments in important areas of our lives such as work, school, relationships, and reduce quality of life. In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must:
● Be out of proportion to the situation or be age-inappropriate
● Hinder their ability to function normally
Anxiety disorders are the most common of mental disorders. They affect nearly 30% of adults at some point in their lives. (American Psychiatry Association, 2024) Anxiety disorders are the most common mental health concern in the United States. Over 40 million adults in the U.S. (19.1%) have an anxiety disorder. Meanwhile, approximately 7% of children aged 3-17 experience issues with anxiety each year. Most people develop symptoms before the age of 21. (National Alliance on Mental Health, 2024). Anxiety is a common illness among older adults, affecting as many as 10-20 percent of the older population, though it is often undiagnosed. (American Association for Geriatric Psychiatry, 2022)
Types of Anxiety Disorders
There are several types of anxiety disorders. We will look at the common anxiety disorders in older adults.
Generalized Anxiety Disorder (GAD) is believed to be the most common anxiety disorder among older adults. People who have GAD find themselves constantly worrying about many things. They fear the worst in every situation, even if that fear is unfounded. Adults suffering from GAD may feel like they're always on edge and in a high state of alert. They may understand that their nervousness is excessive but feel a lack of control over their emotions. General Anxiety Disorder tends to be more common among older women compared to older men, particularly in the event of divorce, separation, or the loss of a spouse or partner.
Social anxiety disorder: Adults with social anxiety feel extreme nervousness and self-consciousness in everyday scenarios involving other people. They fear judgment from others and worry they'll do something to embarrass themselves. They may actively avoid social situations and have a hard time making and maintaining friendships.
Phobia: If a person has an extreme, debilitating fear of something that does not pose a major threat—and this fear leads to avoidance of specific situations or objects—it's called a phobia. Some common phobias include dental procedures, the outside world (agoraphobia), heights, insects, thunderstorms, and driving a vehicle.
Obsessive-compulsive disorder (OCD): Older adults with OCD struggle with unwanted, recurring thoughts or compulsions. They often feel that by performing certain actions repeatedly (e.g., counting the number of tiles on the floor), they will be able to feel a sense of control. Intrusive disturbing thoughts, like being injured in a car accident, are also a form of OCD. (Bryant et al., 2013, 872-876) (Cecchini et al., 2023) (National Council on Aging, 2024)
What is happening in a brain with anxiety disorder?
Anxiety disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety.
● Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior. It gets the body ready for action to fight danger. But what if no danger exists? Then, anxiety compels the sufferer to keep running from an invisible monster to an unknown destination and causes anxiety disorders which interfere with daily life.
● Fear is an emotional response to an immediate threat and is more associated with a fight or flight reaction – either staying to fight or leaving to escape danger. Fear is directed towards a specific stimulus; when the stimulus is gone, so is the fear. Anxiety does not go away when the stimulus is gone because sometimes there is no stimulus! Particularly with the common generalized anxiety disorder, it is just a vague sense of intense worry and certainty that something dangerous will happen. (Azab, 2018),(American Psychiatry Association, 2024)
What is happening in the brain to magnify these infrequent threats? There seems to be an imbalance between the emotional and thinking inhibitory parts of the brain. Typically, the prefrontal cortex inhibits the emotional amygdala. The amygdala is a brain structure that is always on the lookout for threats so it can quickly react. You need it to be in full operation during a dangerous situation. However, in non-threatening situations, a healthy prefrontal cortex inhibits the lower parts and puts the brakes on the accelerated speed of the amygdala.
In the anxious brain, the amygdala is hypersensitive and the connections with the PFC become weaker. So, the amygdala generates too many false alarms such as perceiving a benign situation, comment, evaluation as very threatening. At the same time, the prefrontal cortex is ineffective at inhibiting the amygdala’s diarrhea of thoughts. This process causes great pain as evidenced by activating brain pain areas such as the anterior cingulate cortex. (Azab, 2018)
Anxiety also has detrimental effects on memory. Anxiety causes great stress to the sufferer and stress shrinks the hippocampus. This region is crucial for processing long-term and contextual memories. But here is the unfortunate part: All types of memories become limited except memories that support the anxiety, trauma, or stressor. In other words, the only memory files available for immediate conscious access are the ones of failure, threat, and danger. And the memories of success, certainty, and safety become inaccessible or buried deep in the basement. (Azab, 2018)
Therefore, the mind of a person with anxiety disorders differs from those without anxiety disorders. The following are some of the most common miscalculations of the anxious mind:
● They overestimate the likelihood of negative future events.
● They underestimate how much power they have over changing negative situations.
● They over-plan to accommodate all possible future scenarios.
● They fail to lower pessimism after success (faulty re-calibration of prediction error).
● They have a hyper-focused attention system.
● They are blind to available safety options. (Azab, 2018)
Neuroscientists discovered that in anxiety disorders there is hyperactivity in the amygdala, and the inability of the prefrontal cortex to normalize the brain response to stimuli. They concluded that symptoms of anxiety disorders are associated with a disruption of the emotional processing center in the brain. (Martin et al., 2009, 549-575)
What are the symptoms of anxiety disorders?
Anxiety disorders are a group of related conditions, each having unique symptoms. However, all anxiety disorders have one thing in common: persistent, excessive fear or worry in situations that are not threatening. In general, mental and behavioral signs of an anxiety disorder include:
Uncontrollable feelings of panic, fear, and/or apprehension
Obsessive thoughts
Reactions that are disproportionate to the triggering fear
Restlessness
Trouble with memory and focus
Insomnia
Nightmares
Refusal to engage in routine activities
Ritualistic behaviors (e.g., repeated hand washing)
Anxiety is often accompanied by physical signs such as:
· Racing heart, or heart palpitations
· Trembling
· Hot flashes
· Headaches
· Frequent urination
· Shortness of breath
· Nausea
· Tense muscles
· Excessive sweating
· Cold or sweaty hands
· Dry mouth
While symptoms are an important aspect of diagnosing anxiety in older adults, even more critical is how these symptoms affect day-to-day living. Anxiety is considered problematic when it interferes with your daily functioning, your quality of life, and even your health. (National Council on Aging, 2024), (Rangaves, 2023) Therefore, it is important to be concerned about anxiety disorders that can have serious effects. We will look at the complications of anxiety disorders.
Complications of anxiety disorder
Having an anxiety disorder does more than make you worry. It can also lead to, or worsen, other mental and physical conditions, such as: substance misuse, insomnia, headache, social isolation, suicide, depression, chronic pain, digestive disorders, heart disease, asthma and breathing problems, weakened immune system, and poor quality of life. (Mayo Clinic, 2024) (Advanced Psychiatry Association, 2022) Also, it can interfere with memory, and contribute to amnesia or flashbacks of a traumatic event. Thus, understanding the risk factors of an anxiety disorder help to diagnose and prevent it as well. (American Association for Geriatric Psychiatry, 2022)
Studies on Complications
The aim of the systematic review was to investigate the prevalence of anxiety in Irritable Bowel Syndrome (IBS) patients. Results showed that the prevalence rates of anxiety symptoms and disorders in IBS patients were 39.1% (95% CI: 32.4-45.8) and 23% (95% CI: 17.2-28.8) respectively. Researchers concluded that patients with IBS have a three-fold increased odds of anxiety. (Zamani et al., 2019, 132-143)
The aim of cohort study between 1992 and 2020, was to determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED). Results showed that there was a significantly higher proportion of patients with any type of CED in those with an anxiety disorder in all patients. Researchers concluded that CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events. (Jaskanwal et al., 2021)
Results of a comparative study highlighted that anxiety disorders are significantly associated with Asthma. There is a bi-directional asthma-anxiety relationship, each of which can be caused or resulted from the other. (Del Giacco et al., 2016, 44-53)
Results of the comprehensive review and meta-analysis of 16 studies, involving over 1.4 million participants, provided compelling evidence of a significant association between anxiety and autoimmune diseases. Individuals with anxiety had a 1.28 times higher risk of developing autoimmune diseases compared to those without anxiety. This association was particularly strong for specific autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus. (Amiri & Brizziarelli, 2023)
What leads to an anxiety disorder?
Multiple situational and environmental triggers as risk factors can contribute to an anxiety disorder:
● Extreme stress or trauma
● Bereavement and complicated or chronic grief
● Alcohol, caffeine, drugs (prescription, over-the-counter, and illegal)
● A family history of anxiety disorders
● Other medical or mental illnesses
● Neurodegenerative disorders (like Alzheimer’s or other dementias)
The stresses and changes that sometimes go along with aging—poor health, memory problems, and losses—can cause an anxiety disorder. Common fears about aging can lead to anxiety. Many older adults are afraid of falling, being unable to afford living expenses and medication, being victimized, being dependent on others, being left alone, and death.
Older adults and their families should be aware that health changes can also bring on anxiety. Anxiety disorders commonly occur along with other physical or mental illnesses, including alcohol or substance abuse, which may hide the symptoms or make them worse.
It’s also important to note that many older adults living with anxiety suffered an anxiety disorder (possibly undiagnosed and untreated) when they were younger.
A stressful event, such as the death of a loved one, can cause a mild, brief anxiety, but anxiety that lasts at least six months can get worse if not treated.
Video: Common causes of Anxiety
If your anxiety is having a negative impact on your life, it's time to speak to your healthcare provider. They'll likely start with a complete physical exam to help rule out any potential medical causes of your symptoms. If there are no signs of physical illness, your provider may refer you to a licensed mental health counselor, psychologist, or psychiatrist. These professionals are specially trained to diagnose anxiety, depression, and other mental health disorders through interviews and other assessment tools. We will look at the seeking treatment behaviors for anxiety disorders among older adults. (American Association for Geriatric Psychiatry, 2022) (National Council on Aging, 2024)
Seeking treatment behaviors
Older adults with anxiety disorders often go untreated for a number of reasons. Older adults often do not recognize or acknowledge their symptoms. When they do, they may be reluctant to discuss their feelings with their physicians. Some older adults may not seek treatment because they have suffered symptoms of anxiety for most of their lives and believe the feelings are normal. Both patients and physicians may miss a diagnosis of anxiety because of other medical conditions and prescription drug use, or particular situations that the patient is coping with. For example, the anxiety suffered by a recently widowed patient may be more than normal grieving. Complicated or chronic grief is often accompanied by persistent anxiety and grieving spouses may avoid reminders of the deceased.
Untreated anxiety can lead to cognitive impairment, disability, poor physical health, and a poor quality of life. Fortunately, anxiety is treatable with prescription drugs and therapy. That's why it is important to know that an anxiety disorder is not something you can control or something that will go away. It’s considered a chronic health condition that requires medical treatment, just like diabetes or high blood pressure. (American Association for Geriatric Psychiatry, 2022), (National Council on Aging, 2024)
What are treatment options?
Treatment can involve psychotherapy and medications. Additionally, self-care can play an important role in supporting treatment. When seeking professional help, mental health care providers can determine if there is an underlying condition or medication side effects, then helping to choose treatment options.
Psychotherapy, including cognitive behavioral therapy. Cognitive Behavioral Therapy (CBT) is the most researched psychotherapy for anxiety disorders. In general, CBT focuses on finding the counterproductive thinking patterns that contribute to anxiety. CBT offers many constructive strategies to reduce the beliefs and behaviors that lead to anxiety. (National Alliance on Mental Health, 2024)
Video: Example of 5 CBT exercises for anxiety. This is a little long, but can be very helpful in learning how to deal with anxiety.
Medications, including anti-anxiety medications and antidepressants can help alleviate feelings of panic or nervousness and help to function more normally. Also, beta-blockers can help relieve anxiety by preventing the physical symptoms of anxiety disorders.
Self-care, it’s important to seek professional help and learn how to remain resilient during difficult times. Here are some ways you can help yourself move forward:
○ Learn about medications (for example, when it should begin to help and in what way) and side effects.
○ Tell your doctor about any other drugs (both prescription and over-the-counter), herbal supplements, or alternative therapies you are taking.
○ Find out when and how the medication should be stopped. Some medications cannot be stopped abruptly and must be tapered down under a doctor’s supervision. Some medications are only effective if taken regularly. (American Association for Geriatric Psychiatry, 2022), (National Council on Aging, 2024)
○ Avoid or cut down on alcohol and don’t use illicit drugs, which can make anxiety worse.
○ Exercise regularly, even if it’s just a short walk.
○ Stick to regular eating and sleeping habits as much as possible and eat a healthy diet.
○ Learn relaxation techniques, such as slow breathing and progressive muscle relaxation.
○ Develop the habit of mindfulness meditation, even if it’s just a few minutes per day.
○ Limit news of current events. It is important to stay current, but too much negative news can contribute to anxiety.
○ Allow time for treatment to work. (World Health Organization, 2017)
○ Find support, share your thoughts, fears and questions with others. National Alliance on Mental Illness (NAMI) provides you with support and information about community resources for you and your family. Find education programs and support groups at your local National Alliance on Mental Illness (NAMI). Contact the NAMI HelpLine at 1-800-950-NAMI (6264) or info@nami.org if you have any questions about anxiety or want help finding support and resources.
Video: Mindfulness with CBT can be effective to helping with anxiety. This short video discusses that.
Video: 4 minute mindfulness practice for anxiety
Concerned about an older family member or friend?
If you suspect an older adult you know might have a problem with anxiety, notice and ask about any changes in:
● Daily routines and activities. Is the person avoiding situations and activities he or she once enjoyed?
● Worries. Does he or she seem to worry excessively?
● Medication. Is he or she taking a new medication, either prescription or over-the-counter? Or has the dosage changed for one of the medications?
● Is he or she drinking more alcoholic drinks than previously?
● Mood. Is the older adult tearful, lacking emotion, or “just doesn’t feel right.”
When talking to an older adult who has an anxiety problem:
● Be calm and reassuring
● Acknowledge their fears but do not play along with them
● Be supportive without supporting their anxiety
● Encourage them to engage in social activities
● Offer assistance in getting them help from a physician or mental health professional (American Psychiatry Association, 2024)
Summary
An anxiety disorder causes feelings of fear, worry, apprehension, or dread that are excessive or disproportional to the problems or situations that are feared. Severe anxiety is not a normal part of aging, and you don’t have to accept living with it. If excessive worry is keeping you from a happy and productive life, talk to your doctor. If you know someone suffering from anxiety, let them know that they don’t need to live in psychological pain. Today’s anxiety treatments are safe and effective and can help you feel like yourself again.
References
Advanced Psychiatry Association. (2022, December 7). How Anxiety & Depression Impacts Your Physical Health. Advanced Psychiatry Associates. Retrieved March 31, 2024, from https://advancedpsychiatryassociates.com/resources/blog/the-effects-of-anxiety-and-depression-on-your-physical-health/
American Association for Geriatric Psychiatry. (2022, October 27). Anxiety - Anxiety and Older Adults: Overcoming Worry and Fear. American Association for Geriatric Psychiatry. Retrieved March 31, 2024, from https://www.aagponline.org/patient-article/anxiety-and-older-adults-overcoming-worry-and-fear/
American Psychiatry Association. (2024). Psychiatry.org - What are Anxiety Disorders? American Psychiatric Association. Retrieved March 31, 2024, from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders
Amiri, D., & Brizziarelli, L. (2023, September 18). The Association Between Anxiety and Autoimmune Diseases: A Systematic Review and Meta Analysis of 16 Studies. Journal of Vaccines, Immunology, and Immunopathology. https://doi.org/10.29011/2575-789X.0001100
Azab, M. (2018, April 13). Inside the Thinking Maze of Anxious Minds. Psychology Today. Retrieved March 31, 2024, from https://www.psychologytoday.com/us/blog/neuroscience-in-everyday-life/201804/inside-the-thinking-maze-anxious-minds
Azab, M. (2018, November 29). The Pain of Worry: The Anxious Brain. Psychology Today. Retrieved March 31, 2024, from https://www.psychologytoday.com/us/blog/neuroscience-in-everyday-life/201811/the-pain-worry-the-anxious-brain
Bryant, C., Mohlman, J., Gum, A., Stanley, M., Beekman, A. T., Wetherell, J. L., Thorp, S. R., Flint, A. J., & Lenze, E. J. (2013, September). Anxiety disorders in older adults: Looking to DSM5 and beyond…. The American journal of geriatric psychiatry, 21(9), 872-876. 10.1016/j.jagp.2013.01.011
Cecchini, C., Golden, K. E., & Gershman, J. (2023, May 1). Anxiety in Older Adults: Causes, Symptoms, and Treatment Options. GoodRx. Retrieved March 31, 2024, from https://www.goodrx.com/conditions/generalized-anxiety-disorder/anxiety-in-older-adults
Del Giacco, S. R., Cappai, A., Gambula, L., Manconi, P. E., Carpiniello, B., & Pinna, F. (2016, September 21). The asthma-anxiety connection. Respiratory Medicine, 120, 44-53. https://doi.org/10.1016/j.rmed.2016.09.014
Jaskanwal, S. D. S., Ahmad, A., Toya, T., Pardo, L. S., Lerman, L. O., & Lerman, A. (2021, August 28). Anxiety Disorders Are Associated With Coronary Endothelial Dysfunction in Women With Chest Pain and Nonobstructive Coronary Artery Disease. Journal of the American Heart Association, 10(17). https://doi.org/10.1161/JAHA.121.021722
Martin, E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009, September). The Neurobiology of Anxiety Disorders: Brain Imaging, Genetics, and Psychoneuroendocrinology. Psychiatric Clinics of North America, 32(3), 549-575. https://doi.org/10.1016/j.psc.2009.05.004
Mayo Clinic. (2024). Anxiety disorders - Symptoms and causes. Mayo Clinic. Retrieved March 31, 2024, from https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961
National Alliance on Mental Health. (2024). Anxiety Disorders. NAMI. Retrieved March 31, 2024, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Anxiety-Disorders
National Council on Aging. (2024). What Anxiety Disorders Are Most Common for Older Adults? National Council on Aging. Retrieved March 31, 2024, from https://www.ncoa.org/article/anxiety-and-older-adults-a-guide-to-getting-the-relief-you-need
Rangaves, D. (2023, December 6). How to Rewire Your Anxious Brain: A Complete Guide. Re-origin. Retrieved March 31, 2024, from https://www.re-origin.com/articles/how-to-rewire-your-anxious-brain
World Health Organization. (2017, November 9). Anxiety Disorders. World Health Organization. Retrieved March 31, 2024, from https://doi.org/10.29011/2575-789X.0001100
Zamani, M., Alizadeh-Tabari, S., & Zamani, V. (2019, June 3). Systematic review with meta-analysis: the prevalence of anxiety and depression in patients with irritable bowel syndrome. Alimentary Pharmacology and Therapeutics, 50(2), 132-143. 10.1111/apt.15325