Anxiety Is Often a Symptom, Not a Diagnosis

Why did people come to see me in my psychiatric practice? Yes, bad things happen. Divorce, sickness, etc. But most people to whom these things happen do not seek psychiatric help. When people came for help it was because they felt bad. My soon-to-be patients found themselves nervous, overwhelmed, sad, irritable, or in some similar state. Psychiatrically speaking, they were either anxious or depressed.

Here I’ll focus on anxiety as it is such a common occurrence. Our goal here is not to make a diagnosis for anyone, but rather to construct a map to guide you towards important areas of consideration. This is the same map used by psychiatrists. Keep in mind that I’ll be making generalizations that apply to most people. There are always exceptions, which is why a mental health professional is key in this process.

There are two other things to keep in mind: one is that being upset about difficult things is not a psychiatric issue. It only becomes so if it persists beyond normal expectations and makes your life unusually difficult. Second is that any of the descriptions below is infrequently a prelude to severe mental illness. Again, this is why having a mental health professional on your side is so important (and will be another post).

So, let’s begin with a definition of anxiety. Anxiety is the response of a mature brain to a perceived threat, but one that is not clearly defined. I say “mature brain” as a matter of brain development past childhood. And “not clearly defined” is when the specific threat is not obvious. When it is, we experience fear.

Children may have anxiety (despite their non-matured brains), but it is much less common than in adults. Children’s response to perceived threat is usually emotional outbursts. This is also the case in people with significant developmental disabilities or brain injuries.

Anxiety is experienced in one of two patterns: generalized anxiety or panic. In brief, generalized anxiety is worry, sweaty palms, and tight muscles; while panic is sudden attacks of multiple bodily symptoms such as palpitations, dizziness, chest pain, numbness, and shortness of breath along with feelings of dread.

The important thing to know about anxiety in psychiatry is that it is ubiquitous. All psychiatric disorders can, and often do, bring anxiety with them. Generalized anxiety and panic may exist on their own and then become a diagnosis of an anxiety disorder, but more commonly they are part of another diagnosis. The exact diagnosis depends on the person’s age, what other symptoms they have, and what is happening in their life. (I have left out medical reasons; aside from hyperthyroidism, medical problems are rarely the explanation for anxiety).

Anxiety in Childhood

I am not a child psychiatrist, and this issue is big enough for an article on its own. But we can summarize a few points. Anxiety is less common in children than in teens and adults. But it still has a significant prevalence, which is sadly growing. Early anxiety, such as separation anxiety and phobias (e.g. fear of the dark, dogs, bugs), is not uncommon in children, especially preschoolers, and these can be part of development and usually pass with time.

This is contrasted with temperamental anxiety, a part of their personality, which also begins in early childhood. This is more characterized by behavioral inhibition, avoidance of new things, general nervousness, and social anxiety. These are all much stronger predictors of anxiety later in life and this temperament is usually lifelong. Panic disorder, though, is rarely seen in childhood.

It is also important to consider environmental issues, such as family discord, problems in school, such as bullying, and related issues. Family history of anxiety or other psychiatric issues can also play a role.

School-age children with some of the problems listed above, such as temperament, along with OCD and tantrums, are even stronger predictors of other types of psychiatric problems later in life.

Good predictors of problems later in life are important, but do not solve problems at hand. Irrespective of what they may predict, a qualified clinician should evaluate and treat whatever is present. Some pediatricians have had strong training in this, but many do not. Usually, a child psychiatrist or psychologist is a better approach.

Anxiety in Adolescence

Anxiety in teens presents the same questions: age of onset, environmental life issues, and type of symptoms. I will just mention a few pathways. One is with new-onset panic attacks. This usually suggests panic disorder, often with accompanying agoraphobia. This includes many different fears such as fear of open spaces, closed spaces, distance from home, crowds, etc. These all represent a fear of being away from safety should a panic attack occur, as panic produces the sense that you are very ill.

The other pathway, which may present the same way, is into depression. In teens, as with younger children, expect schoolwork and social life to change for the worse when depression rears its head. This will be what stands out to parents and teachers, so a specialist must ask the right questions to find out about depression.

My own view, which is not the official psychiatric view currently, is that panic disorder is a prelude to depression. Current data finds that over half of panic patients will develop depression. I believe the actual number is higher.

Lastly, adolescence is when severe mental illness usually begins to show. This is the exception not the rule, but a good clinician will know when to investigate further.

Anxiety and depression are in many ways two sides of the same coin. They occur together, are inherited together, and are treated in very similar or identical ways. Patients with panic attacks virtually always become depressed in my experience.

Anxiety in Mid-Life or Adulthood

This is a good bridge into adulthood, with the 20s being a crossover where patterns from adolescence or patterns from adulthood can occur. Moving into adulthood and middle life, the 30s through 50s, new anxiety is associated with depression unless it is a symptom of some significant life stressor.

Such stressors are sadly common in this period of life and include divorce, unemployment, financial problems, new medical problems, and death of parents. These could be extremely stressful times emerging from normal feelings of loss to significant anxiety and often, depression.

Anxiety in Late Life

Lastly, moving into the 50s, 60s, and 70s, new anxiety is still associated with depression, but there is an important caveat. Namely, this depression is biologically not like the depressions occurring in all the younger periods of life. It does not include the family history of depression that is more common in these other patients. The question for psychiatrists then is, what is this late-life depression if it is not like earlier depressions?

Part of the answer is that it is the beginning of dementia. The risk is roughly 25-35% of these patients will develop dementia, but this varies. The higher risk is when the first depression is later in life (age 75 is higher risk than 55), and other dementia risk factors are present.

So, if you or someone you care about develops anxiety, the first thing to do is not to search the internet for an article on anxiety disorders. As we have discussed, look at the age of onset of the anxiety, the type of anxiety, what’s happening in the person’s life, and other potentially important symptoms (especially depression or cognitive symptoms in older people). Anxiety is a symptom, not a diagnosis. Understanding the full context of the anxiety will lead you to a better idea of what is happening to you or someone you care about and thus more helpful treatment.