ANXIETY
What is anxiety? What are its nature, types, degree, causes, effects, and
responses? Anxiety may be seen as a natural response to stressful situations and be
accompanied by feelings of worry, nervousness, and/or apprehension (Australian
Psychological Society, 2022). When these feelings do not resolve after the stressful
situation has passed, become excessive, or compromise the health and wellbeing of
a client, there may be an anxiety issue needing intervention. These feelings of
excessive worry may lead to avoidance of situations felt to be associated with the
anxiety (Beck & Hindman, 2021). The risk is that this avoidance of internal and external
stimuli decreases the healthy interaction a person has with their world and the people
within it (Australian Bureau of Statistics, 2022a). In this way, the ‘safety behaviours’
actually increase rather than decrease anxiety (Centre for Clinical Interventions,
2021). Ultimately, clients experience anxiety within many situations they face. What is
important for counsellors to identify are the potential factors that can lead to an
increase in anxiety and interventions that have been found to decrease the impact of
anxiety. Both are discussed later in this chapter. The interventions are explored
through Reavley et al.’s (2019) analysis of evidence-based approaches.
It is important to distinguish between productive and unproductive anxiety. Not
all anxiety is “irrational, abnormal and neurotic … the capacity to be anxious is a
biological function necessary for survival” (Rycroft, 1988, p. xii). Our evolutionary
history required the quick assessment of potential threats. Anxiety formed the basis of
‘life or death’ decisions (Arden & Linford, 2009). When walking into traffic we
unconsciously respond using our evolved ‘predatory defense’ (LeDoux & Pine, 2016),
treating the traffic as if a predator threatening our survival. We instantly stop our
forward motion and return to safety. In contrast to the obvious external threat of traffic,
we may also experience anxiety when internal signals indicate conditions such as low
energy supplies, fluid imbalance, or hypothermia (LeDoux & Pine, 2016). Crocq (2015)
argued, not only is anxiety “a normal emotion” but it is “adaptive since it promotes
survival by inciting persons to steer clear of perilous places” (p. 319). It is also
described as an inborn and adaptive emotion (Glick & Roose, 2010; Mulhare et al.,
2010; Ray et al., 2017).
Clients usually only seek assistance for their anxiety when it moves beyond a
short-term response to events they face. This persistence impacts the client in a
variety of ways, including reducing their engagement in their world (Craske & Stein,
2016) and may “eclipse critical priorities” (Westra, 2012, p. 3) including education,
career, relationships, leisure activities, and feelings of contentment. Whilst anxiety
might be seen as common, the distress, impairment, and reduced quality of life require
attention and interventions to reduce its impact (Westra, 2012).
Fear appears to be at the centre of all anxiety issues (Arden & Linford, 2009;
Craske et al., 2009; Duits et al., 2015; Dunsmoor & Paz, 2015; Milad et al., 2014; Stein
et al., 2007). So the words ‘fear’ and ‘anxiety’ are often used interchangeably. Further,
in the literature no distinction is made between the subjective states of fear and
anxiety, or the different systems involved in each (LeDoux & Pine, 2016). It is perhaps
more accurate, according to LeDoux and Pine (2016), to consider both fear and
anxiety as both mental states and subjective feelings. These states and feelings are
underpinned by different behavioural and physiological responses. This distinction
highlights the differences between feelings of fear, which arise when a threat “is either
immediate or imminent” to the client and specific in nature, and anxiety, which arises
when the threat “is uncertain or is distal in space or time” or further away from the
client (LeDoux & Pine, 2016, p. 1084). Additionally, anxiety is not circumstance or
context-specific, rather it is non-specific in nature (Craske & Stein, 2016; LeDoux &
Pine, 2016). A further distinction is between anxietus or trait anxiety (i.e., being prone
to anxiety due to a tendency to respond to various situations with concerns and worry,
e.g., generalised anxiety) and angor or state anxiety (i.e., current anxiety that tends to
be transitory after the situation passes, e.g., dental anxiety) (Crocq, 2015; Saviola et
al., 2020).
Anxiety is also used as a clinical term to suggest a particular type of mental
disorder category, as described in the ICD-11 (World Health Organization, 2022a), or
DSM-5-TR (American Psychiatric Association, 2022). Different forms of anxiety are
categorised according to their intensity, usually expressed as mild, moderate, or
severe. Distinctions are also made based on the characteristics of each presentation
of anxiety. Depending on the presentation, anxiety may be categorised into:
• generalised—a free-floating form that something is just not right
• phobic—associated with situations such as giving a speech, sensations such as fear
of falling, or fear of animals or insects such as cats or spiders
• as part of post-traumatic stress disorder (PTSD)—episodic, acute, associated with
flashbacks, and can be triggered to the level of the panic attack by stimulus like a car
backfiring
• complex PTSD (C-PTSD)—the consequence of repeated or chronic traumatisation
and repeated losses leading to the person organising their life around survival
(Schwartz, 2021)
• obsessive compulsive disorder (OCD)—fear that a catastrophe is waiting to happen
and can be forestalled by the use of rituals such as putting things in a particular order
or scrubbing the hands alongside or part of a medical issue (Arden & Linford, 2009).
The general diagnostic criteria for anxiety include:
• feeling very worried or anxious most of the time
• finding it difficult to calm down
• feeling overwhelmed or frightened by sudden feelings of intense panic/anxiety •
experiencing recurring thoughts that cause anxiety, but may seem silly to others •
avoiding situations or things which cause anxiety (e.g., social events or crowded
places)
• experiencing ongoing difficulties (e.g., nightmares/flashbacks) after a traumatic event
(Reavley et al., 2019, p. 6).
The Australian Psychological Society (2022) adds characteristics of difficulty
concentrating, restlessness, rapid heartbeat, trembling or shaking, feeling lightheaded
or faint, numbness or nausea, and/or sweating. Clients may also experience nausea,
stomach pains, tension in neck and shoulders, sleep issues, and irritability as anxiety
builds (Australian Government, Department of Health and Aged Care, 2019). Rather
than focusing on specific anxiety disorders as per DSM-5-TR (APA, 2022) and ICD11
(WHO, 2022), this chapter takes a broader approach to include aspects of anxiety
which involve biological, psychological, social, developmental, and contextual
elements as well as their interplay. This aligns with Eifert and Forsyth’s (2005)
suggestion that looking at common processes involved in the establishment and
maintenance of anxiety related issues can lead to more effective and impactful
interventions.
PREVALENCE
Anxiety is considered a common mental health issue both in Australia and
globally. In its 2022 World mental health report, the World Health Organization (WHO,
2022b) noted both the commonality of anxiety and its increase by 25% during the first
year of the pandemic. The Australian Bureau of Statistics (ABS) reported 16.8% or 3.3
million people in Australia reported anxiety in the 12 months of 2020–2021 (2022a).
The ABS figures were further broken down into panic disorder (3.7%), agoraphobia
(4.6%), social phobia (7.0%), generalised anxiety disorder (3.8%), obsessive
compulsive disorder (3.1%), and post traumatic stress disorder (5.7%). These f igures
represent people who have been diagnosed; however, they do not represent people
who may have diagnosable anxiety yet remain undiagnosed or those whose anxiety
is not at the level required for diagnosis.
RISK FACTORS
The World Health Organization (WHO, 2022b) identified a diverse set of
individual, family, community, and structural circumstances that all contribute to mental
health. Additionally, the combination of life experiences and genetic predisposition may
increase anxiety into a more intense form of anxiety (Hofer, 2010). These diverse
factors are included when assessing anxiety from a biopsychosocial perspective
(Engel, 1977). Anxiety, from this perspective, is seen as a combination of the biological
factors of the person, the psychological factors of the person, and their reciprocal
interactions with the social aspects of the person (Engel, 1977). This can be
complemented by developmental theories from Bronfenbrenner (ecological model)
and Samorof (transactional model). These models emphasise the importance of
seeing the biopsychosocial factors within the broader context and culture of a person’s
life. These factors interact and develop over the lifetime of the person and are unique
to the historical time of that person (Lehman et al., 2017). While any person can
develop anxiety, there are some additional risks based on specific characteristics. It is
beyond the scope of this chapter to discuss all the potential risk groups and factors.
However, some are discussed next.
GENDER
The ABS(2022) reported that gender comparisons show females are more
likely than males to develop anxiety (21% compared to 12.4%). Drilling further down
into the statistics, females were more likely than males to have social anxiety (9.8%
compared with 5.7%) and post-traumatic stress disorder (7.6% and 3.6%) (ABS,
2022). This is a consistent finding in the research on anxiety (Cabral & Patel, 2020).
These differences may be due to biological differences in brain structure which are
impacted by genes, hormones, and environment. Gender role expectations, power
dynamics, vulnerability to impacts of domestic violence and sexual assault, and other
risk factors may also impact. These factors may be combined with misogyny,
discrimination, being seen as inferior to males, and lower rates of pay that affect
females (Rodgers et al., 2020). Gender is a complex and not yet clearly understood
dynamic of anxiety.
AGE
In the 16–24 year old age group in Australia, almost a third (31.5%) were
identified as having anxiety, including 41.3% of females (ABS, 2022). Anxiety may be
compounded by sleep issues. This is particularly relevant to this age
groupduetothebraindevelopmentatthis time. Issues with sleep can be exacerbated by
social media and other technologies, and potentially associated cyberbullying (Cabral
& Patel, 2020). Bandelow and Michaelis (2015) reported that anxiety issues start in
childhood and adolescence or early adulthood, peak in middle age, then tend to
decrease with older age. This pattern was identified in epidemiological studies and
supported by Craske and Stein (2016), who further argued that it is important to identify
people at risk and commence interventions as early as possible. Longitudinal studies,
according to Pine and Fox (2015), typically suggest that adults who exhibit chronic
anxiety had experienced it from childhood. It is, therefore, not surprising to find the
age group of 16–24 year old has a high rate for anxiety. It is also important to consider
that anxiety may arise in later periods due to exposure to accidents, illness, and other
issues. So anxiety, whilst most prevalent in earlier stages of life, can continue or arise
in later stages. Additional areas of concern for youth include separation anxiety,
selective mutism, social anxiety, and generalized anxiety (Palitz & Kendall, 2020).
Excessive and developmentally inappropriate anxiety from actual or imagined
separation from caregivers in youth over six years old is seen as separation anxiety.
As Palitz and Kendall (2020) noted, similar separation anxiety before six years old is
considered developmentally appropriate. Social anxiety may arise in youth as
avoidance of social situations, avoiding asking questions in class, difficulties with
starting or joining conversations, and is present both with adults and peers. Selective
mutism is a failure to speak in certain situations despite being able to speak in others.
It is important to note that when youth have one form of anxiety, they have a roughly
80% chance of a co-existing anxiety issue of another form (Palitz & Kendall, 2020). Of
additional concern in the youth age group is the increased risk of self-harm and
suicide. While the median age of suicide is 44.8 years, there is a higher rate of suicide
in youth (Suicide Prevention Australia, 2022). This is something to be mindful of at any
age but is particularly important as the brains of youth develop, impulse control and
risk analysis may be low, and feelings of anxiety and isolation can be overwhelming.
IDENTIFICATION
The ABS (2022) reported that 44.7% of people who identify as gay, lesbian,
bisexual, asexual, pansexual, or queer reported anxiety. People in these groups may
encounter stigma, prejudice, and discrimination leading to a social environment that
can be both stressful and hostile (Hill et al., 2020). These phenomena may present in
medical treatment that is culturally insensitive or misinformed, violence and
harassment, lack of family support, and workplace mistreatment (Rodgers et al.,
2020).
SOCIAL CIRCUMSTANCES
There are a range of social circumstances that potentially affect the prevalence
of anxiety. People living in one parent family households with dependent children
(28.7%) reported anxiety (ABS, 2022). Low socioeconomic status contributes to higher
rates of anxiety (Moreno-Peral et al., 2014). Existential concerns can trigger anxiety.
These concerns may include not leading a meaningful life or the eventuality of death
(LeDoux & Pine, 2016). Stressful events which are ongoing and/or uncertain may also
trigger anxiety, for example, being a new parent, work changes, relationship issues,
and the death of loved ones (Reavley et al., 2019).
FAMILY FACTORS
Based on epidemiological studies, heritability of anxiety issues is estimated to
be between 30–50% (Shimada Sugimoto et al., 2015). Factors increasing anxiety risk
for children include parental anxiety issues (Beesdo Baum & Knappe, 2012; Strawn et
al., 2020) and certain parental personality disorders (cluster A and cluster C)
(Kaplowitz & Markowitz, 2010; Strawn et al., 2020). Children are also at an increased
risk of a variety of mental health issues, including anxiety, through: childhood
maltreatment and neglect (Chu et al., 2013; Vachon et al., 2015); physical punishment
in childhood (Clauss & Blackford, 2012);. and over-protective or overly harsh parenting
style (Beesdo-Baum & Knappe, 2012). Attachment research has highlighted the
increased risk of anxiety issues in children with an anxious attachment style (Bowlby,
1973). This includes all forms of insecure attachment as these styles raise anxiety
sensitivity and contribute to viewing others as undependable, result in chronic anxiety,
increase difficulty in emotional regulation, and cause cognitive errors about threats
(Mulhare et al., 2010). Similarly, separation anxiety (from major attachment figures)
has been studied by researchers as a form of persistent, developmentally
inappropriate anxiety (Bögels et al., 2013; Comer & Olfson, 2010). The authors report
that one third of childhood separation anxiety persists into adulthood (Comer & Olfson,
2010) while Silove et al. (2015) reported over 43% of lifetime separation anxiety had
an onset after 18 years of age. Separation anxiety can also reform into other forms of
anxiety and depression.
ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES
Reavley et al. (2019) reported high levels of psychological distress, including
feelings of anxiety, in Aboriginal and Torres Strait Islander peoples. The identified
causes of anxiety in this group of peoples needs to be understood through the
existence of intergenerational trauma, and social, historical, cultural, and spiritual
factors. These causes include racism and discrimination, loss of cultural identity, being
away from country, and not being able to have ceremony. Further information on this
issue can be found in the Intergenerational Trauma Animation below [4:02].
CULTURALLY AND LINGUISTICALLY DIVERSE (CALD)
People from culturally and linguistically diverse (CALD) backgrounds represent
a significant group within Australia. The ABS (2021) reported just over 7 million
(27.6%) of the population (almost 26 million) were born overseas (ABS, 2022). A range
of issues may arise from being in the CALD group and may contribute to anxiety or
other mental health issues. These include increased stigma in their native cultures
around mental health issues as well as concerns about trust and confidentiality when
interacting with providers of health services (Baker et al., 2016). This lack of trust is
particularly understandable for those who have experienced human rights violations
and persecution leading to their relocation (Phillips, 2015). Trauma, and its associated
anxiety, may arise from a variety of causes in their homelands—such as poverty,
political unrest, gang violence, and natural disasters (Amnesty International, 2022).
Appreciating such potential for trauma may be contributing to presenting anxiety is an
important aspect of working with people from CALD.
INDIVIDUAL ATTRIBUTES
Many individual attributes contribute to anxiety risk. For example, Clauss and
Blackford‘s (2012) meta-analysis found behavioural inhibition, such as clinging to
familiar others in the presence of strangers, was specifically predictive of social
anxiety. Tendencies towards perfectionism, being easily flustered, timid, inhibited,
having low self-esteem, and/or wanting to control everything can contribute to anxiety
in childhood, adolescence, and adulthood (Beyond Blue, 2022). So too can certain
thinking styles including anticipating the worst, and persistent negative self-talk. These
can occur alongside difficulty accepting uncertainty, low self-esteem, sensitivity to
internal physical responses, such as increased heart rate, and misinterpreting these
physical symptoms as indicating something catastrophic (APA, 2022). A tendency to
misinterpret ambiguous situations contributes to a range of emotional issues including
anxiety in both social and generalised forms. This tendency for misinterpretation also
contributes to specific issues such as body dysmorphia (Dietel et al., 2021). Body
dysmorphia is related to physical appearance interpretation bias (reduced positive and
increased negative). This interpretation bias promotes social anxiety which also has a
higher fear of negative evaluation (Fang & Hoffman, 2010).
COPING MECHANISMS
Some coping mechanisms work well to reduce the development and impact of
anxiety. These are often referred to as adaptive coping mechanisms. They sit
alongside protective factors to reduce the risk of developing ongoing anxiety. However,
clients will often be drawn to coping mechanisms that may negatively impact their
anxiety. Some coping mechanisms that place a client at greater risk of anxiety include
the use of substances such as alcohol, cannabis, amphetamines, sedatives, emotional
eating, gambling, and so forth. These can reduce effects of anxiety initially but increase
the anxiety when the effects of the coping mechanism begin wearing off (Reavley et
al., 2019). A common coping mechanism is avoidance. Avoidance is mentioned by
researchers such as Dietel et al. (2021) and features in the diagnostic criteria for
anxiety disorders (APA, 2022; WHO, 2022a).
LIFE EVENTS
While many life events may involve or contribute to anxiety, this chapter focuses
here on four examples of life events where anxiety can arise. The first two relate to
common developmental issues—having a baby, and ageing. These show that specific
life events that are developmentally common can give rise to anxiety containing both
general and specific aspects. The second two relate to specific issues that give rise to
both general and specific forms of anxiety—athletic competition, and test anxiety.
Having a baby
The impact of having a baby is far-reaching. One impact can be maternal
anxiety which may arise or increase in the post-natal period (Seymour et al.,
2015). Seymour et al.’s 2015 study of 224 Australian mothers of infants (aged
0–12 months) identified that 18% had mild to extremely severe symptoms of
anxiety. The flow on effects of this anxiety included fewer close, warm and
affectionate interactions with their infants alongside less involvement in their
infant’s learning activities such as playing indoors and reading stories. When
co-existing depression was evident, there was also a sense of lower efficacy
andsatisfaction as a parent, and high parental hostility. Factors that contributed
to maternal anxiety included lower educational attainment, perceived need for
social support, poor couple relationship, difficult child behaviour, and poor
quality of sleep.
Ageing
Older people often experience anxiety alongside other issues related to
both physical and mental health. Of import, according to Andreescu and Lee
(2020), late-life generalised anxiety disorder, for example, has a more severe
course and impact. Additionally, bidirectionality exists in the causal relationship
between late-life anxiety and cognitive impairment. Impaired cognitive
performance increases anxiety on one hand and chronic anxiety states may
increase the risk for central nervous system damage due to the impact of
chronically elevated cortisol, blood pressure, or excessive benzodiazepine
prescriptions. Anearlier study by Andreescu et al. (2008) showed prevalence
rates of generalised anxiety disorder for those in residential community care to
be similar to the general population. In older people, however, they identified
additional anxieties connected to impairments in the quality of life, cognitive
impairment, increased health care utilisation, and poorer functional recovery
after disabling medical events such as stroke. What is also important to note is
that those people in the 60+ age group have a different profile to those under
60 years old including higher rates of uncontrolled worry and different worry
content.
Athletic competition
Given Australia is such a sporting nation, it seems relevant to include
something on the anxiety associated with athletic competition. Athletes
experience anxiety from factors faced by the general population as well as
athlete-specific factors, such as pressure to perform, public scrutiny, career
uncertainty or dissatisfaction, and injury (Vu & Conant-Norville, 2021). Specific
forms of anxiety that may be experienced by athletes include: injury-associated
anxiety (related to the injury itself or not being able to compete); somatic state
anxiety (where afear of failure or internalizing worries is expressed physically);
cognitive state anxiety (where hope for success is reduced due to the
memorable expression of anxiety); and competitive anxiety (which tends to
increase before and during competitions and when those contests are away
from home). Vu and Conant-Norville (2021) stress the importance of
responding to both the general and specific contributors to anxiety in athletes.
This principle seems more widely applicable to clients who have anxiety so they
are not responded to with generic interventions but ones which are tailored to
their specific needs.
Test anxiety
Test anxiety has been selected as an example as some readers of this
chapter may be students affected by this form of anxiety. This specific form of
anxiety is an important one to consider as it impacts on the capacity of a person
to engage successfully with studies. Lotz and Sparfeldt (2017) argued that test
anxiety is a transitory or state anxiety related to possible negative
consequences of failure on an exam as opposed to the more stable trait test
anxiety in which the predisposition is to interpret test situations as overly
threatening.
