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Earlier this month, the U.S. Preventive Services Task Force recommended anxiety screening for adults under the age of 65. The draft recommendations are designed to help primary care clinicians identify early signs of anxiety during routine care, using questionnaires and other screening tools. Although they did not specify a particular tool, the one commonly used is the GAD-7 scale.
Last week, the organization force posted final recommendation statements on screening for anxiety, depression, and suicide risk in children and adolescents. The task force recommends screening children 12 and older for depression and, for the first time, is recommending screening children ages 8 and older for anxiety.
As a psychiatrist who specializes in treating people with medically unexplained symptoms, I applaud this bold action. Approximately 30 percent of the adult population in North America experiences anxiety. One-third of this population is either not diagnosed, misdiagnosed, or does not come forward to be evaluated. This means that ten percent of the overall adult population in North America doesn’t know they have issues with anxiety.
Anxiety is the body’s response to a stressful situation, such as attending a significant event or speaking in public. It is normal to feel nervous or apprehensive in these circumstances. However, some individuals experience these emotions in situations that are not typically stress-inducing. They may have physical symptoms, such as a racing heart, dizziness, and chest tightness.
But what if you don't know that what you're feeling is anxiety?
Daniel is a 30-year-old man who called my office for a consultation at the recommendation of a family friend. He has a mop of dirty blond hair that he wears slightly long. He attended an Ivy League school and works for a prestigious law firm in downtown Washington, D.C. He arrived early for his appointment, wearing pressed khakis, a neat button-down shirt, his “college tie” and loafers. He said his main concern was with his stomach. Although only 30 years old, he was already very impressive, having clerked for a U.S. Court of Appeals judge prior to joining the firm as an associate, and is well on his way to becoming a partner.
Although he has no difficulty completing his legal assignments, when asked to meet with clients or senior partners at a lunch or dinner engagement, he feels the urgent need to vomit. His fear about this is so great, he forgoes eating for the entire day, reasoning that, if his stomach is empty, he will not throw up. Unfortunately, there are times when, despite this restriction, he retches or experiences dry heaves. This poses a significant problem because he works in a field where meetings over meals with clients are commonplace. He tries to deal with his symptoms by consuming alcohol frequently and using marijuana regularly to fall asleep.
Daniel completed a full gastrointestinal workup prior to seeing me. No medical reason for his symptoms could be found. So, what did explain his puzzling symptoms?
Daniel has a disorder called “functional vomiting.” Not a very appealing sounding diagnosis, it is defined as recurring, unexplained vomiting that occurs at least once per week, and has no obvious medical basis to explain the symptoms. It is rare in the general population and has not received a lot of investigation, but it can be disabling.
In 2010, investigators at a hospital in Peking studied a group of patients with functional vomiting and found the most common triggers for the vomiting episodes were “emotional change” and “noxious stress.” In layman’s terms, this means the cause of the physical symptoms is anxiety.
You may not recognize that you are anxious, and instead experience physical symptoms caused by your brain transmitting stress to the remainder of the body. If you think of your brain as your body’s central computer, it has an enormous amount of “USB ports” that are connected to your organ systems. If your brain is anxious, it sends the alarm to the rest of your major organ systems.
Why are some individuals unable to recognize they are anxious?
- Misperception: Some individuals may think of anxiety as a mental health condition about which they have to be worried all the time. This is not necessarily true. Anxiety can show up in different ways.
- Normalization: Many anxious people grow up thinking their behaviors are normal and not due to anxiety. If you grow up in a household in which one or more family members are anxious, this may seem like the norm rather than something that can be diagnosed and treated.
- Somatic equivalents: Somatization is the process by which individuals experience and express their feelings or emotions through physical complaints and distress. This may result from a variety of cultural, familial, and personal circumstances, including biases against expressing psychological discomfort.
- Stigmatization: Individuals may fear being stigmatized if they are labeled with a psychiatric disorder, or may be concerned about their physician's response to non-physical complaints. A study of 1,000 anxious primary care patients found that 40 percent experienced at least one, but often more than one, somatic complaint, and only 16 percent of these patients had symptoms that later correlated with a known medical disease over a three-year period.
What are some clues that you might be anxious even if you don’t feel that way?
- Problems sleeping: Anxiety causes sleep problems, and new research suggests sleep deprivation can cause an anxiety disorder. Studies also show that people with chronic insomnia are at high risk of developing an anxiety disorder.
- Poor concentration: Anxiety and problems with memory are interconnected. As anxiety symptoms escalate, the mind struggles to stay on task. Short-term memory functions are affected by anxiety as well, causing difficulty in remembering tasks or projects that are due, only adding to work performance challenges.
- Changes in appetite: Although many people binge eat or indulge in rich foods when stressed, there’s a small group of people who lose their appetite during moments of high anxiety.
- Increased Irritability: When a person is experiencing anxiety, they will often be more irritable than usual. It is a common symptom of many types of anxiety disorders. If your body and mind are overwhelmed with worry, you can feel stressed and depleted of energy. This can make it difficult for you to shrug off or ignore things you normally would. This can, in turn, cause you to become more irritable.
- Increased alcohol consumption. Alcohol may seem like a simple, prescription-free option for calming your nerves and coping with uncomfortable feelings. However, it can worsen anxiety symptoms, which may lead to a cycle of heavy drinking and even alcohol addiction. Liquor stores remained open and were considered essential businesses during the COVID pandemic. Using data from a national survey of U.S. adults, excessive drinking (such as binge drinking) increased by 21 percent during that time.
- Experiencing one or more physical symptoms that are out of proportion to what can be found on physical exams or laboratory studies.
This is by no means an exhaustive list of symptoms that may mean you are suffering from anxiety. However, if you suspect you may have anxiety symptoms, you are not alone. Visit your primary care physician. Ask to be screened for anxiety. There is excellent treatment available and with proper care recovery rates are excellent.
Here are some excellent resources if you believe you may have an anxiety disorder:
- Anxiety and Depression Association of America https://adaa.org/
- National Alliance on Mental Illness (NAMI); 800-950-NAMI (800-950-6264)
- Anxiety and Depression Association of America (ADAA); 240-485-1001.
- National Institute of Mental Health (NIMH); 866-615-6464.
- Centers for Disease Control and Prevention, Division of Mental Health (CDC); 800-CDC-INFO (800-232-4636)
To find a therapist near you, visit the Psychology Today Therapy Directory.
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