It often starts subtly. A racing heart before a meeting, a restless night filled with what-ifs, or the sudden desire to cancel plans just in case something goes wrong. It’s easy to dismiss these moments. Everyone worries, after all. But over time, the unease lingers. Thoughts loop through worst-case scenarios, the chest feels tight for no clear reason, and everyday tasks begin to feel exhausting.
This creeping discomfort reflects an elevated sensitivity to threat – a characteristic that is now recognised as a core feature across anxiety disorders, shaping how individuals think, feel, and respond to the world around them (Craske et al., 2011). It doesn’t always announce itself as a full-blown panic attack. Sometimes, it arrives disguised as overthinking, avoidance, or the need to be constantly in control.
Importantly, anxiety often does not occur alone. Many individuals also experience depression alongside anxiety, a co-occurrence that can compound emotional distress and further complicate help-seeking. Recognising when anxiety begins to interfere with the ability to live, work, or connect meaningfully with others is a vital step toward support.
Globally, anxiety disorders are the most common mental health condition, affecting an estimated 301 million people in 2019 (World Health Organization [WHO], 2023). Although anxiety disorders are highly treatable, research shows that only around one in four people receive adequate care.
In Singapore, as in many parts of the world, individuals experiencing anxiety may delay seeking help due to stigma, lack of resources, a lack of awareness, or uncertainty about the nature of their symptoms. Recognising the difference between everyday anxiety and a clinical disorder is a crucial first step. Psychological therapies offer practical, evidence-based interventions that can help individuals regain a sense of control and improve their mental wellbeing.
Table of Contents
What is an Anxiety Disorder?
Anxiety disorders are a group of mental health conditions characterised by excessive fear or worry that is difficult to control and disproportionate to the actual situation. While some anxiety is expected in response to life’s challenges, anxiety disorders persist over time and interfere with a person’s ability to function in daily life (American Psychiatric Association, 2022).
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), anxiety disorders include a range of conditions such as generalised anxiety disorder (GAD), panic disorder, social anxiety disorder, specific phobias, and others. These conditions share core features of heightened arousal and avoidance, often accompanied by physical symptoms such as muscle tension, sleep difficulties, rapid heartbeat, or gastrointestinal discomfort.
A key feature of anxiety disorders is their impact on functioning. Individuals may avoid situations that trigger their anxiety, withdraw socially, or experience ongoing worry that affects concentration, work, or relationships. In children and adolescents, anxiety disorders can also affect academic performance and development of social skills (WHO, 2023).
It is important to note that anxiety disorders are psychiatric conditions, not character flaws or signs of weakness. They result from a complex interaction of biological, psychological, and environmental factors, and can affect people of all ages and backgrounds. Early identification and appropriate treatment, including psychotherapy, have been shown to reduce symptoms and improve long-term outcomes (Domschke & Maron, 2013).
Anxiety Disorder or Regular Anxiety?
Most people experience anxiety at some point, whether it’s before a big work presentation, while waiting for exam results, or when juggling multiple responsibilities at home and in the office. In such cases, anxiety can be adaptive. It helps to heighten focus, improve preparedness, and protect us from potential harm.
However, anxiety becomes clinically significant when it is persistent, excessive, and interferes with daily life. Unlike situational anxiety, which usually resolves once the stressor is removed, anxiety disorders tend to linger for months or even years. Individuals may experience intense physical symptoms, such as rapid heartbeat or shortness of breath, even in the absence of an identifiable stressor.
Anxiety may cross into disorder when it causes significant distress, leads to avoidance of normal activities, or begins to affect work and relationships. For instance, while it is natural to feel nervous before a job interview, choosing not to attend the interview due to overwhelming fear may signal a more serious issue.
The following comparison can help distinguish between everyday anxiety and an anxiety disorder:
Day-to-Day Anxiety
- Related to a specific event or stressor
- Temporary and subsides with time
- Does not interfere significantly with daily activities
- Mild physical symptoms, manageable without intervention
- Helpful in some situations (e.g. motivates preparation)
Anxiety Disorder
- Often occurs without a clear cause
- Persistent, lasting six months or more
- Interferes with work, relationships, or self-care
- Intense physical symptoms such as panic attacks or insomnia
- Disruptive and distressing, with limited functional benefit
Day-to-Day Anxiety
Anxiety Disorder
- Related to a specific event or stressor
- Temporary and subsides with time
- Does not interfere significantly with daily activities
- Mild physical symptoms, manageable without intervention
- Helpful in some situations (e.g. motivates preparation)
- Often occurs without a clear cause
- Persistent, lasting six months or more
- Interferes with work, relationships, or self-care
- Intense physical symptoms such as panic attacks or insomnia
- Disruptive and distressing, with limited functional benefit
It is also possible to experience anxiety symptoms without meeting the full diagnostic criteria for a specific anxiety disorder. In such cases, clinicians may diagnose the condition as “anxiety disorder not otherwise specified” (anxiety NOS), recognising that the symptoms still warrant attention and care. These experiences are valid and may benefit from psychological support. If anxiety is causing distress or limiting a person’s ability to live fully, seeking guidance from a mental health professional is a constructive and important step.
What Happens in the Brain During an Anxiety Attack
When anxiety strikes, the experience is often felt across both body and mind: a pounding heart, tight chest, racing thoughts, and an urge to escape or shut down. These sensations are rooted in biological processes, particularly in how the brain perceives and responds to potential threats.
At the centre of this response is the limbic system, a group of brain structures involved in emotion, memory, and survival instincts. Key regions include the amygdala, which assesses threats and initiates fear responses; the hippocampus, which encodes memories and links them to emotional reactions; and the hypothalamus, which regulates the body’s stress response through the autonomic nervous system (Hyde et al., 2011).
When the brain detects danger, whether a real threat or a perceived one, the amygdala activates the hypothalamic-pituitary-adrenal (HPA) axis, releasing stress hormones such as cortisol and adrenaline. This cascade initiates the well-known “fight or flight” response, preparing the body to act quickly by increasing heart rate, muscle tension, and alertness (Mariotti, 2015).
However, the brain’s stress response is more nuanced than simply fight or flight. Experts now recognise four common survival strategies in responses to threat: fight, flight, freeze, and fawn.
- Fight: confronting the threat with aggression or high alertness
- Flight: attempting to escape or avoid the situation entirely
- Freeze: shutting down mentally or physically when escape isn’t possible
- Fawn: trying to appease others in an effort to reduce perceived threat
During an anxiety attack, these reactions are often automatic, driven by the emotional brain, particularly the amygdala, while the prefrontal cortex, which governs rational thinking and self-regulation, becomes less active. This helps explain why individuals may feel detached from reality or unable to think clearly in the moment (Liu, Zhao, & Guo, 2018).
When anxiety becomes chronic, these brain circuits can change structurally. Research suggests that prolonged anxiety may enlarge the amygdala, making individuals more sensitive to perceived threats over time (Qin et al., 2014). At the same time, elevated levels of cortisol – the body’s primary stress hormone – can shrink the hippocampus, a region essential for memory and learning. This, along with changes in the prefrontal cortex, can impair emotional regulation, memory processing, and decision-making (Mariotti, 2015).
This neurological feedback loop helps explain why anxiety may feel increasingly difficult to control without support. Fortunately, psychological therapies, particularly those grounded in cognitive-behavioural principles, can help retrain the brain’s response to stress, offering long-term relief and improved self-regulation.
Causes of Anxiety Disorders
Anxiety disorders arise from a complex interplay of biological, psychological, and environmental influences. While no single factor can fully explain why someone develops an anxiety disorder, researchers agree that certain vulnerabilities and life circumstances can increase risk (Domschke & Maron, 2013; WHO, 2023).
Biological Factors
There is strong evidence that genetic predisposition plays a role in anxiety. Family and twin studies suggest that individuals with a family history of anxiety or mood disorders are more likely to develop anxiety themselves, though it remains challenging to fully separate inherited traits from the influence of environmental modelling, such as anxious parenting (Domschke & Maron, 2013). Brain imaging studies also suggest heightened activity in the amygdala and other regions involved in emotional regulation among individuals with anxiety (Hyde et al., 2011).
In addition, imbalances in neurotransmitters including serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) have been linked to heightened anxiety responses. These chemicals influence mood, arousal, and the brain’s ability to regulate stress (Liu, Zhao, & Guo, 2018).
Certain medical conditions, such as hyperthyroidism, cardiovascular disease, chronic respiratory issues, or gastrointestinal disorders, may also contribute to the development or worsening of anxiety symptoms (Mayo Clinic, 2023). In some cases, anxiety can be the first sign of an underlying health issue.
Psychological Factors
Several psychological traits and early life experiences can contribute to anxiety vulnerability. These include:
- Perfectionism and a tendency to worry excessively, which have been associated with greater anxiety symptom severity (Smith et al., 2018)
- Shy or inhibited temperament in childhood, which may predict anxiety in adolescence and adulthood (Prior et al., 2000)
- Low self-esteem, which can increase sensitivity to perceived threats or failure (Sowislo & Orth, 2013)
Additionally, unhelpful thinking patterns such as catastrophising or overgeneralising may contribute to the maintenance of anxiety, especially when left unchallenged over time.
Environmental Factors
Anxiety often emerges in response to life stressors, particularly those involving loss, uncertainty, or perceived danger. Traumatic experiences, such as abuse, neglect, or sudden bereavement, can significantly increase one’s risk of developing an anxiety disorder (WHO, 2023).
More subtle, cumulative stress, for example, ongoing financial difficulties, work pressure, or academic demands, can also contribute to anxiety over time. Environmental modelling plays a role as well; growing up in a household where caregivers display high anxiety or controlling behaviours may influence a child’s own anxiety responses.
Substance misuse or withdrawal from substances such as alcohol, stimulants, or benzodiazepines can also intensify anxiety symptoms (Mayo Clinic, 2023).
Types of Anxiety Disorders
Anxiety disorders encompass a range of conditions that share the core features of excessive fear, worry, and behavioural avoidance. While they differ in their specific triggers and symptoms, they are all associated with significant distress and can interfere with daily life.
Below are the most commonly recognised types of anxiety disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2022).
Note: The symptoms listed here are not exhaustive, and experiences can vary widely across individuals. If you’re concerned about anxiety symptoms, even if they don’t “fit the box” perfectly, it is still valid to seek support. Labels can guide treatment, but they do not define the whole person.
Generalised Anxiety Disorder (GAD)
People with GAD experience persistent and excessive worry about various aspects of daily life, such as work, finances, health, or relationships. The worry is often difficult to control and may be accompanied by symptoms like restlessness, fatigue, irritability, difficulty concentrating, and muscle tension. To meet diagnostic criteria, symptoms must be present on most days for at least six months.
Panic Disorder
Panic disorder involves recurrent, unexpected panic attacks – sudden episodes of intense fear that peak within minutes. During a panic attack, individuals may feel breathless, dizzy, or as though they are having a heart attack. The fear of future attacks can lead to behavioural avoidance, which may further impair functioning.
Social Anxiety Disorder (Social Phobia)
This condition is marked by intense fear of being judged, embarrassed, or humiliated in social or performance situations. Individuals with social anxiety may avoid public speaking, eating in front of others, or attending gatherings. Symptoms often emerge in adolescence and can be chronic without treatment.
Specific Phobias
A phobia is an intense and irrational fear of a specific object or situation such as heights, flying, animals, or medical procedures. The fear is out of proportion to the actual danger posed, but still causes significant distress and avoidance. Exposure to the feared object often provokes immediate anxiety or even panic.
Agoraphobia
Agoraphobia involves a fear of situations where escape might be difficult or help unavailable if anxiety symptoms occur. This may include crowded spaces, public transport, or being outside the home alone. In severe cases, individuals may become housebound.
Separation Anxiety Disorder
Although often associated with children, separation anxiety can also affect adults. It involves intense distress at the thought of being apart from attachment figures, such as family members or partners. Symptoms may include nightmares, physical complaints, or refusal to be alone.
Selective Mutism
Primarily diagnosed in children, selective mutism is characterised by the inability to speak in specific social situations despite being able to speak comfortably in others (such as at home). It can interfere with academic, social, and emotional development.
Existential and Death Anxiety
Beyond clinical categories, some individuals experience existential anxiety, profound anxiety related to questions of meaning, mortality, or life’s purpose. Related to this is death anxiety, a crippling fear of death or dying, which may surface during life transitions, illness, or after significant loss. While not classified as a disorder on its own, these forms of anxiety can strongly impact wellbeing and are valid areas of concern that can be addressed in psychotherapy.
Alleviating Anxiety Through Therapy
Anxiety can feel overwhelming, but it is also highly treatable. Psychological therapies offer structured, evidence-based strategies that help individuals understand their anxious thoughts, challenge unhelpful patterns, and build coping skills for long-term change. The following modalities are among the most well-established approaches used by therapists today.
Cognitive Behavioural Therapy (CBT)
CBT is one of the most widely studied and effective treatments for anxiety disorders (Norton & Price, 2007). It works by helping individuals identify and change unhelpful thought patterns that contribute to anxiety. For example, someone who consistently overestimates danger or underestimates their ability to cope might learn to evaluate these thoughts more realistically.
CBT often includes behavioural experiments, where clients gradually face feared situations and track the outcomes. Over time, this process can reduce avoidance and build confidence.
Mindfulness techniques are sometimes integrated into CBT, although it is important to note that mindfulness-based therapies such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are also distinct therapeutic approaches in their own right. These therapies use mindfulness practice as a central component to help individuals become more aware of their thoughts and bodily sensations without judgement, and have shown promising results in reducing both physiological and emotional symptoms of anxiety (McClintock, Rodriguez & Zerubavel, 2019).
Exposure Therapy
Exposure therapy is a subtype of CBT used especially for phobias, panic disorder, and social anxiety. The goal is to reduce fear by gradually and repeatedly facing the feared situation or object in a safe, controlled way. Over time, the brain learns that the situation is not dangerous, weakening the anxiety response.
This process, known as habituation, allows individuals to rebuild their tolerance and reduce avoidance behaviours that can reinforce anxiety over time.
Solution-Focused Brief Therapy (SFBT)
SFBT is a goal-oriented approach that focuses on what is working in a person’s life rather than exploring the root causes of problems. It is particularly helpful for clients who are looking for short-term support to manage anxiety more constructively.
Therapists using SFBT help clients envision a future where anxiety feels more manageable, and then explore practical steps to get there. This strengths-based focus can be empowering and especially appealing to those who may feel stuck in cycles of overanalysis.
Acceptance and Commitment Therapy (ACT)
Rather than trying to eliminate anxiety, ACT teaches individuals to accept their internal experiences while committing to actions aligned with their values. The idea is not to avoid uncomfortable thoughts or feelings, but to change the relationship one has with them.
Through mindfulness, values clarification, and behavioural activation, ACT helps individuals live a fuller life even in the presence of anxiety. It is especially helpful for people who feel they must “get rid of” their anxiety before they can start living meaningfully.
Group Counselling
For some, the most healing aspect of therapy is the realisation that they are not alone. Group counselling provides a space to share experiences, learn coping strategies, and receive support from others who understand what it’s like to live with anxiety.
Facilitated by a trained therapist, anxiety-focused groups can help normalise the experience of anxiety, reduce shame, and build social connection, which in itself can be a protective factor against worsening mental health.
Conclusion
Living with anxiety can be exhausting, isolating, and at times, disheartening. But it is not something that has to be endured. Anxiety disorders are not personal failings; they are treatable conditions, shaped by a combination of biological, psychological, and environmental factors.
Beyond being just a space for reflection, psychotherapy offers structured, evidence-based strategies that support individuals in understanding their anxiety, challenging unhelpful patterns, and cultivating a more grounded sense of self. Whether through cognitive behavioural therapy (CBT), Solution-Focused Brief Therapy (SFBT), group counselling, or other modalities, therapy can support a shift from simply coping to reclaiming autonomy and wellbeing.
For those interested in supporting others on their mental health journeys, The School of Positive Psychology’s Postgraduate Diploma in Psychotherapy and Counselling offers a comprehensive, human-centred training pathway. Rooted in positive psychology and clinical best practice, the programme equips future psychotherapists with the skills and insight to make a meaningful difference.
While anxiety may constrict the world of those who experience it, with the right support, it need not define it.
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