When is anxiety normal and when is it a disorder? A psychiatrist explains

Is it normal to feel this anxious all the time? How do I know if it’s too much?

These are questions many of my patients ask.

Anxiety affects all of us and can be thought of as tension or worry about a situation or stressor.

Anxiety can be adaptive and is a necessary survival skill, given that our environments can be dangerous and unpredictable.

An anxiety response is a way of heightening attention to and preparing defences against something that can threaten our bodies, physical space or loved ones.

It can lead to productive behaviours such as escaping danger or seeking ways to improve a situation (for instance, experiencing anxiety about climate change and examining what we can do to help).

But anxiety can be maladaptive when it is excessive or is not connected to an objective threat.

There are ways to know the difference between adaptive and maladaptive anxiety.

An anxiety disorder activates our brain differently

An anxiety disorder can make it hard to function on a day-to-day basis (for instance, interfering with work or home activities), given that it is intense and time-consuming.

Another distinction is in brain activation.

The brain’s salience network is responsible for drawing our attention to emotionally relevant signals, both within and outside the body.

While there is some circuitry overlap in adaptive and maladaptive anxiety, in an anxiety disorder there may be heightened and more persistent activation of the salience network, especially with emotionally charged situations.

This can stimulate the release of stress hormones (such as cortisol and norepinephrine), keeping us on high alert.

Importantly, other networks that could help reroute our attention or calmly think through the situation can be underrecruited.

This leaves us with a rigid, emotion-based reasoning that seeks “confirmation” of biased cognitions.

For instance, someone with social anxiety might feel constantly judged by others: “If people smile at me, I figure they’re mocking me in their heads. If they are whispering to someone else, I just know they’re talking about me and how ridiculous I am.”

Anxiety disorders affect the body as well, causing physical symptoms such as rapid breathing and heart rate, sweating, gastrointestinal upset, restlessness and shaking.

This is part of a vicious cycle — anxiety can lead to “body prediction errors,” as increased salience network activation signals that our body is in danger even though there is no objective threat.

This can make it hard to feel safe, giving us a sense that we cannot understand or control what is driving our anxiety.

Maladaptive anxiety can feel like a perpetual loop.

Even if we have been in similar situations before and made it through, it can be easy to forget this and feel as if we’re going through the same gantlet time and again.

As one patient who experienced severe anxiety whenever he was in a particular social scenario said, “The whole thing feels like torture. I’m sweating and shaking before and while I’m in it. Once I get out, it’s like a wave of relief. I feel I survived something. Every time, it’s the same.”

How to cope when anxiety is interfering with our life

Be patient with yourself:

The neural wiring that promotes anxiety responses develops early in life, often before we encode lasting, conscious memories. We can become conditioned to react in strong ways without understanding why. This is driven both by genetics and by the environments we are raised in, and for all of us, there will be situations that elicit greater tension and worry.

Beating ourselves up for something we cannot control will not improve the situation. It’s not realistic for anyone to have a smooth, calm reaction to all of life’s scenarios.

Discover control where you can:

The difference between a situation being resilience building or overwhelming is often determined by how much control we have. The “stress inoculation hypothesis” posits that mild, manageable stress-inducing situations can help strengthen brain areas that dampen emotional reactivity, fostering resilience to future stress.

Anxiety responses to certain triggers can be significantly lessened when exposure to them is gradual and doesn’t exceed our tolerance level. Exposure that is too much, too soon (what would be termed “flooding”) may cause us to do anything to escape the anxiety, thus strengthening the belief that the situation cannot be dealt with.

Putting ourselves in situations that cause mild, but not overwhelming anxiety, and sitting with the feeling without seeking to get rid of it, can help us gain some control over our reactions.

We learn that we can handle more than we imagined, feeling less at the mercy of our anxiety.

Consider whether medications can help:

If anxiety is making it difficult to function, and other measures have not helped, medications may decrease symptoms and improve quality of life. (The goal is not to erase our emotions or eliminate anxiety.)

Some medications are taken every day, and others only as needed (when in anxiety-provoking situations).

When effective, medications can help us shift our thinking — if we do not feel as anxious in a situation that would usually elicit strong reactions, we might reframe how threatening a given stressor actually is.

Psychiatric medications may also help us engage with other forms of treatment such as psychotherapy, which is not always easy to do, as we may need to process distressing topics for it to be effective.

Christopher W.T. Miller, MD, is a psychiatrist and psychoanalyst practicing at the University of Maryland Medical Center and an associate professor at the University of Maryland School of Medicine. He is the author of “The Object Relations Lens: A Psychodynamic Framework for the Beginning Therapist.”