Is best thought of as a negative mood state that is marked by bodily symptoms such as accelerated pulse muscle tension feeling uneasy and worries about the future?

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Stress and anxiety-related disorders
Differential Diagnosis
Review Questions

Medically reviewed by Kendra Kubala, PsyD, Psychology — By The Healthline Editorial Team — Updated on February 17, 2022

Stress is any demand placed on your brain or physical body. Any event or scenario that makes you feel frustrated or nervous can trigger it.

Anxiety is a feeling of fear, worry, or unease. While it can occur as a reaction to stress, it can also happen without any obvious trigger.

Both stress and anxiety involve mostly identical symptoms, including:

trouble sleeping
digestive issues
difficulty concentrating
muscle tension
irritability or anger

Most people experience some feelings of stress and anxiety at some point, and that isn’t necessarily a “bad” thing. After all, stress and anxiety can sometimes be a helpful motivator to accomplish daunting tasks or do things you’d rather not (but really should).

But unmanaged stress and anxiety can start to interfere with your daily life and take a toll on your mental and physical health.

Here’s a closer look at stress and anxiety, how they differ, and how to find support for managing both.

The big difference between stress and anxiety is the presence of a specific trigger.

Stress is typically tied to a specific situation. Once that situation resolves, so does your stress.

Maybe you have an upcoming exam that you’re worried about taking. Or you’re trying to juggle working from home with three small children who are competing for your attention. In both cases, there’s a specific root of your stress. Once the exam is over or your children return to daycare, your stress starts to go away.

That doesn’t mean stress is always short-lived, though. Chronic stress refers to long lasting stress that occurs in response to ongoing pressure, like a demanding job or family conflict.

Anxiety, by contrast, doesn’t always have a specific stressor.

While stress and anxiety are different things, they’re closely connected.

In some cases, stress might trigger anxiety. If you’re stressed about a big upcoming move, for example, you might find that you start to feel generally nervous about nothing in particular.

Not sure whether stress or anxiety is behind your symptoms?

Take a step back and think of what’s going on in your life right now. What kinds of things do you tend to worry about? Are they specific threats or events?

Consider car troubles. Maybe you know you really need new tires, especially now that it’s starting to snow. But you can’t afford to replace them just yet.

For the next few weeks, you feel uneasy about driving. What if you slide on a patch of ice? What if you get a flat on your way home from a late-night shift on that stretch of road with lousy reception?

A few weeks later, you have a fresh set of tires and stop worrying about driving to and from work safely. In this case, your nervousness was due to stress, triggered by having old tires.

But maybe you get new tires and don’t really notice a change in your symptoms. You’re still nervous about driving and feel a vague sense of unease that you can’t quite put your finger on. Or, your tires were never an issue in the first place, but you can shake an overall feeling of nervousness about getting on the road. That would be anxiety.

If you can tie your feelings back to a specific trigger, they’re likely the result of stress. But if the exact cause isn’t clear, or your symptoms stick around after the initial trigger goes away, it may be anxiety.

Stress typically happens in response to physical or mental pressure. This pressure might involve a big life change, like:

moving
starting a new school or job
having an illness or injury
having a friend or family member who is ill or injured
experiencing the death of a family member or friend
getting married
having a baby

But stress triggers don’t need to be life-altering. You might feel stress due to:

having a long to-do list to tackle over the weekend
attending a big work meeting
having a looming deadline for a project

Stress and anxiety that occur frequently or seem out of proportion to the stressor could be signs of an underlying condition, including:

Generalized anxiety disorder (GAD). This is a common anxiety disorder characterized by uncontrollable worrying. Sometimes people worry about bad things happening to them or their loved ones, and at other times, they may not be able to identify any source of worry.
Panic disorder. This condition causes panic attacks, which are moments of extreme fear accompanied by a pounding heart, shortness of breath, and a fear of impending doom.
Post-traumatic stress disorder (PTSD). This is a condition that causes flashbacks or anxiety as the result of a traumatic experience.
Social anxiety disorder. This condition causes intense feelings of anxiety in situations that involve interacting with others.
Obsessive-compulsive disorder (OCD). This is a condition that causes repetitive thoughts and the compulsion to complete certain ritual actions.

It’s best to talk with a mental health professional any time stress or anxiety starts to affect your day-to-day life.

Keep in mind: You don’t need to have a specific mental health condition to benefit from therapy. A qualified therapist can help you identify potential triggers and create effective coping mechanisms to minimize their impact, even if you don’t meet the diagnostic criteria for an anxiety disorder.

It’s also worth reaching out if stress or anxiety leaves you feeling hopeless, or if you start having thoughts of harming yourself or others.

If you’re not sure where to start, consider asking your primary healthcare professional for a referral.

Or check out our guide to finding a therapist.

Find more suicide prevention resources here.

Many types of therapy can help with stress and anxiety. A mental health professional can help you find the right approach for your specific symptoms.

Some examples of approaches they might recommend are:

Cognitive behavioral therapy, which teaches you to recognize anxious thoughts and behaviors and change them into more positive ones.
Exposure therapy, which involves gradually exposing you to certain things that trigger anxiety.
Acceptance and commitment therapy, which teaches you how to accept and sit with negative emotions.

Depending on your symptoms, they may also recommend medication to help with anxiety symptoms. These may include selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) or paroxetine (Paxil).

In some cases, a clinician might recommend benzodiazepines, such as diazepam (Valium) or lorazepam (Ativan), but these approaches are generally used on a short-term basis due to the risk of dependence.

While some amount of stress and anxiety in life is expected and shouldn’t be a cause for concern, it’s important to recognize when these feelings are causing negative consequences.

If you feel like your stress and anxiety are becoming unmanageable, a mental health professional can help you develop new coping skills.

Read this article in Spanish.

Last medically reviewed on February 17, 2022

Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (real or perceived). Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening. This activity reviews the pathophysiology of anxiety, its presentation, diagnosis and highlights the role of the interprofessional team in its management.

Objectives:

Identify the DSM V criteria for anxiety disorders.
Describe the presentation of a patient with anxiety.
Outline the treatment and management options available for anxiety.
Discuss interprofessional team strategies for improving care coordination and outcomes for patients with anxiety.

Access free multiple choice questions on this topic.

Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (real or perceived). Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening. Pathological anxiety is triggered when there is an overestimation of perceived threat or an erroneous danger appraisal of a situation which leads to excessive and inappropriate responses.[1][2][3]

Anxiety is one of the most common psychiatric disorders but the true prevalence is not known as many people do not seek help or clinicians fail to make the diagnosis.

Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.

Anxiety can be caused by the following conditions:

Medications
Herbal medications
Substance abuse
Trauma
Childhood experiences
Panic disorders

Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%. The least common anxiety disorder is agoraphobia with a 12-month prevalence rate of 2.5%. Anxiety disorders occur more frequently in females than in males with an approximate 2:1 ratio.[4]

The significant mediators of anxiety in the central nervous system are thought to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). The autonomic nervous system, especially the sympathetic nervous system, mediates most of the symptoms.

The amygdala plays an important role in tempering fear and anxiety. Patients with anxiety disorders have been found to show heightened amygdala response to anxiety cues. The amygdala and limbic system structures are connected to prefrontal cortex regions, and prefrontal-limbic activation abnormalities may be reversed with psychological or pharmacologic interventions.

Characteristic Symptoms Pathological Anxiety

Cognitive symptoms: fear of losing control; fear of physical injury or death; fear of "going crazy"; fear of negative evaluation by others; frightening thoughts, mental images, or memories; perception of unreality or detachment; poor concentration, confusion, distractible; narrowing of attention, hypervigilance for threat; poor memory; and difficulty speaking.

Physiological symptoms: increased heart rate, palpitations; shortness of breath, rapid breathing; chest pain or pressure; choking sensation; dizzy, light-headed; sweaty, hot flashes, chills; nausea, upset stomach, diarrhea; trembling, shaking; tingling or numbness in arms and legs; weakness, unsteadiness, faintness; tense muscles, rigidity; and dry mouth.

Behavioral symptoms: avoidance of threat cues or situations; escape, flight; pursuit of safety, reassurance; restlessness, agitation, pacing; hyperventilation; freezing, motionless; and difficulty speaking.

Affective symptoms: nervous, tense, wound up; frightened, fearful, terrified; edgy, jumpy, jittery; and impatient, frustrated.

Anxiety Disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013):

Separation Anxiety Disorder: An individual with separation anxiety disorder displays anxiety and fear atypical for his/her age and development level of separation from attachment figures. There is persistent and excessive fear or anxiety about harm to, loss of, or separation from attachment figures. The symptoms include nightmares and physical symptoms. Although the symptoms develop in childhood, they can be expressed throughout adulthood as well.
Selective Mutism: This disorder is characterized by a consistent failure to speak in social situations where there is an expectation to speak even though the individual speaks in other circumstances, can speak, and comprehends the spoken language. The disorder is more likely to be seen in young children than in adolescents and adults.
Specific Phobia: Individuals with specific phobias are fearful or anxious about specific objects or situations which they avoid or endure with intense fear or anxiety. The fear, anxiety, and avoidance are almost always immediate and tend to be persistently out of proportion to the actual danger posed by the specific object or situation. There are different types of phobias: animal, blood-injection-injury, and situational.
Social Anxiety Disorder: This disorder is characterized by marked or intense fear or anxiety of social situations in which one could be the subject of scrutiny. The individual fears that he/she will be negatively evaluated in such circumstances. He/she also fears being embarrassed, rejected, humiliated or offending others. These situations always provoke fear or anxiety and are avoided or endured with intense fear and anxiety.
Panic Disorder: Individuals with this disorder experience recurrent, unexpected panic attacks and experience persistent concern and worry about having another panic attack. They also have changes in their behavior linked to panic attacks which are maladaptive, such as avoidance of activities and situations to prevent the occurrence of panic attacks. Panic attacks are abrupt surges of intense fear or extreme discomfort that reach a peak within minutes, accompanied by physical and cognitive symptoms such as palpitations, sweating, shortness of breath, fear of going crazy, or fear of dying. Panic attacks can occur unexpectedly with no obvious trigger, or they may be expected, such as in response to a feared object or situation.
Agoraphobia: Individuals with this disorder are fearful and anxious in two or more of the following circumstances: using public transportation, being in open spaces, being in enclosed spaces like shops and theaters, standing in line or being in a crowd, or being outside of the home alone. The individual fears and avoids these situations because he/she is concerned that escape may be difficult or help may not be available in the event of panic-like symptoms, or other incapacitating or embarrassing symptoms (e.g., falling or incontinence).
Generalized Anxiety Disorder: The key feature of this disorder is persistent and excessive worry about various domains, including work and school performance, that the individual finds hard to control. The person also may experience feeling restless, keyed up, or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability, muscle tension, and sleep disturbance.
Substance/Medication-Induced Anxiety Disorder: This disorder involves anxiety symptoms due to substance intoxication or withdrawal or to medical treatment.
Anxiety Disorder Due to Other Medical Conditions: Anxiety symptoms are the physiological consequence of another medical condition. Examples include endocrine disease: hypothyroidism, hypoglycemia, and hypercortisolism; cardiovascular disorders: congestive heart failure, arrhythmia, and pulmonary embolism; respiratory illness: asthma and pneumonia; metabolic disturbances: B12 or porphyria; neurological illnesses: neoplasms, encephalitis, and seizure disorder.

When the history and examination do not suggest the symptoms as arising from any other medical disorder, the initial laboratory studies may be limited to the following: complete blood cell count (CBC) chemistry profile, thyroid function tests, urinalysis, and urine drug screen.[5][6][7]

If the anxiety symptoms are atypical or there are some abnormalities noted in the physical examination more detailed evaluations may be indicated to identify or exclude underlying medical conditions. This would include the following: electroencephalography, brain computed tomography (CT) scan, electrocardiography, tests for infection, arterial blood gas analysis, chest radiography, and thyroid function tests.

Acute anxiety may require treatment with a benzodiazepine. Chronic anxiety treatment consists of psychotherapy, pharmacotherapy, or a combination of both.

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders. [3][8][9]

SSRIs (fluoxetine, sertraline, paroxetine, escitalopram, and citalopram) are an effective treatment for all anxiety disorders and considered first-line treatment.
SNRIs (venlafaxine and duloxetine) are considered as effective as SSRIs and also are considered first-line treatment, particularly for generalized anxiety disorder (GAD).
Tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline) are useful in the treatment of anxiety disorders but cause significant adverse effects.
Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are used for short-term management of anxiety. They are fast-acting and bring relief within 30 minutes to an hour. They are effective in promoting relaxation and reducing muscular tension and other symptoms of anxiety. Because they work quickly, they are effective when taken for panic attacks or overwhelming episodes. Long-term use may require increased doses to achieve the same effect, which may result in problems related to tolerance and dependence.
Buspirone is a mild tranquilizer that is slow acting as compared to benzodiazepines and takes about 2 weeks to start working. It has the advantage of being less sedating and also not being addicting with minimal withdrawal effects. It works for GAD.
Beta-blockers (propranolol and atenolol) control the physical symptoms of anxiety such as rapid heart rate, a trembling voice, sweating, dizziness, and shaky hands. They are most helpful for phobias, particularly social phobia.

Psychotherapy: One of the most effective forms of psychotherapy is cognitive-behavioral therapy. It is a structured, goal-oriented, and didactic form of therapy that focuses on helping individuals identify and modify characteristic maladaptive thinking patterns and beliefs that trigger and maintain symptoms. This form of therapy focuses on building behavioral skills so that patients can behave and react more adaptively to anxiety-producing situations. Exposure therapy is utilized to move individuals towards facing the anxiety-provoking situations and stimuli which they typically avoid. This exposure results in a reduction in anxiety symptoms as they learn that their anxiety is causing them to experience false alarms and they do not need to fear the situation or stimuli and can cope effectively with such a situation.

Differential Diagnosis

Anxiety disorders have very high morbidity including substance abuse, alcoholism, and major depression. In addition, constant anxiety also increases the risk of adverse cardiac events. In others, anxiety impairs the ability to develop social relationships and worsens the quality of life. Severe anxiety has also been linked to high rates of suicide.

Characteristic Features Noted in Individuals with Clinical Anxiety

False alarms: The presence of intense fear in the absence of threat cues or very minimal threat provocation.
Persistence: There is a future-oriented perspective that involves the anticipation of threat or danger which causes the patient to experience a heightened level of apprehension and thoughts about impending potential threat, regardless of whether it materializes.
Impaired Functioning: Anxiety interferes with effective and adaptive coping in the face of a perceived threat and the person’s daily social or occupational life.
Stimulus hypersensitivity: In clinical states, fear is elicited by a wider range of stimuli or situations of relatively mild intensity that would be innocuous to a person who does not have clinical anxiety.
Dysfunctional cognition and cognitive symptoms: Thinking characterized by overestimation of threat or danger appraisal of a situation that is not confirmed in any way.

Anxiety disorders are very common and can present in diverse ways. Because the condition is underdiagnosed and associated with high morbidity, it is best managed by an interprofessional team consisting of a mental health nurse, psychiatrist, psychotherapist, social worker, and a primary care provider. Family members need to be educated about the disorder and help monitor the symptoms and provide support. A mental health nurse should closely follow these patients as suicidal ideations are not rare. The pharmacist should educate the patient on different medications, their benefits, and potential adverse effects. Collaboration between the team members is vital to ensure that no patient is neglected and that all patients are receiving an acceptable standard of care.

The outlook for patients with anxiety is guarded. Data indicate that the high rates of mortality are associated with adverse cardiac events. In those with social phobia, the condition leads to significant functional impairment and a very poor quality of life. The risk of suicides is also high in this population. Patients with anxiety need lifelong follow-up because, despite drug therapy, relapse rates are high. [2][10][11](Level V)

Review Questions

Hawken T, Turner-Cobb J, Barnett J. Coping and adjustment in caregivers: A systematic review. Health Psychol Open. 2018 Jul-Dec;5(2):2055102918810659. [PMC free article: PMC6236498] [PubMed: 30450216]

Domhardt M, Geßlein H, von Rezori RE, Baumeister H. Internet- and mobile-based interventions for anxiety disorders: A meta-analytic review of intervention components. Depress Anxiety. 2019 Mar;36(3):213-224. [PubMed: 30450811]

Lahousen T, Kapfhammer HP. [Anxiety disorders - clinical and neurobiological aspects]. Psychiatr Danub. 2018 Dec;30(4):479-490. [PubMed: 30439809]

Remes O, Wainwright N, Surtees P, Lafortune L, Khaw KT, Brayne C. Generalised anxiety disorder and hospital admissions: findings from a large, population cohort study. BMJ Open. 2018 Oct 27;8(10):e018539. [PMC free article: PMC6224748] [PubMed: 30368445]

Durazzo M, Gargiulo G, Pellicano R. Non-cardiac chest pain: a 2018 update. Minerva Cardioangiol. 2018 Dec;66(6):770-783. [PubMed: 29642692]

Jafferany M, Khalid Z, McDonald KA, Shelley AJ. Psychological Aspects of Factitious Disorder. Prim Care Companion CNS Disord. 2018 Feb 22;20(1) [PubMed: 29489075]

Cosci F, Fava GA, Sonino N. Mood and anxiety disorders as early manifestations of medical illness: a systematic review. Psychother Psychosom. 2015;84(1):22-9. [PubMed: 25547421]

Chapdelaine A, Carrier JD, Fournier L, Duhoux A, Roberge P. Treatment adequacy for social anxiety disorder in primary care patients. PLoS One. 2018;13(11):e0206357. [PMC free article: PMC6218038] [PubMed: 30395608]

Rickels K, Moeller HJ. Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. World J Biol Psychiatry. 2019 Sep;20(7):514-518. [PubMed: 30252578]

10.

Kreuze LJ, Pijnenborg GHM, de Jonge YB, Nauta MH. Cognitive-behavior therapy for children and adolescents with anxiety disorders: A meta-analysis of secondary outcomes. J Anxiety Disord. 2018 Dec;60:43-57. [PubMed: 30447493]

11.

Pereira AS, Willhelm AR, Koller SH, Almeida RMM. Risk and protective factors for suicide attempt in emerging adulthood. Cien Saude Colet. 2018 Nov;23(11):3767-3777. [PubMed: 30427447]