Anxiety disorders: what they are, why they cause physical symptoms, and how they are treated

What is the difference between normal worry and an anxiety disorder?

Worry is a normal, biologically useful response. It sharpens attention before a difficult task, alerts you to genuine danger and motivates protective action. This kind of anxiety is proportionate, temporary and ends when the situation ends. An anxiety disorder is different in three specific ways: the worry is excessive relative to any real threat, it is difficult to control even when you recognise it is disproportionate, and it persists for weeks or months rather than resolving with the situation.

The clinical benchmark for generalised anxiety disorder is six or more months of excessive worry about multiple areas of life, with associated symptoms such as muscle tension, sleep disturbance, difficulty concentrating, irritability and a persistent sense of dread. This is not overthinking or soft character or a failure of faith. It is a medical condition with a documented neurobiological basis involving sustained overactivity of the threat-detection circuits in the brain.

A study published in Acta Neuropsychiatrica in 2025 tracking anxiety disorder trends across the Middle East and North Africa from 1990 to 2021 found a significant rise in prevalence over that period, with the true burden likely underestimated because of social stigma and the scarcity of mental health services in many countries in the region. Anxiety disorders are common and they are getting more common, not rarer.

Why do so many anxiety patients see a cardiologist first?

Anxiety disorders produce strong, real physical symptoms that closely mimic heart disease and other physical conditions. Palpitations and rapid heart rate, a sensation of pressure or tightness in the chest, shortness of breath, tingling or numbness in the hands or face, sudden sweating and dizziness are all standard features of anxiety disorder and especially of panic disorder. These are not imagined symptoms, they are physiological responses driven by sustained sympathetic nervous system activation.

A study published in The American Journal of Medicine found that between 25 and 30 percent of patients presenting to emergency departments with non-cardiac chest pain met the criteria for panic disorder, and that physicians failed to recognise the diagnosis in the majority of cases. In the Arab world this pattern is reinforced by a cultural tendency to present psychological distress in physical terms, meaning patients themselves often insist on cardiac investigations and resist a mental health explanation even when the physical workup is repeatedly normal.

A narrative review of somatic symptom presentations in the Arab world published in Frontiers in Psychiatry in 2025 confirmed that expressing emotional distress through physical complaints is the dominant pattern in the region, and that this significantly delays accurate diagnosis and appropriate treatment. Understanding this pattern helps both patients and clinicians avoid the trap of endless physical investigation for symptoms that will respond to psychological treatment.

What types of anxiety disorder are there?

Generalised anxiety disorder (GAD) is the most common: excessive, hard-to-control worry that moves between different concerns, work, health, family, minor daily decisions, without settling anywhere. The person with GAD rarely has a period of calm, even when nothing is actually wrong. Associated physical symptoms of muscle tension, poor sleep, difficulty concentrating and fatigue are part of the diagnosis and often the symptoms that finally bring someone to a clinic.

Panic disorder is characterised by recurrent, unexpected panic attacks: sudden surges of intense fear peaking within minutes, accompanied by strong physical symptoms that closely resemble a heart attack. Most attacks resolve within 20 to 30 minutes. What sustains the disorder is the fear of the next attack and the progressive avoidance of places or situations associated with previous episodes, which can eventually make it difficult to leave home.

Social anxiety disorder, specific phobias and obsessive compulsive disorder all sit within the broader anxiety spectrum, with OCD sometimes classified separately in newer diagnostic systems. What these conditions share is a fear response that is disproportionate to any realistic threat, maintained by avoidance behaviours that provide short-term relief while keeping the underlying fear intact. A comprehensive review published in JAMA in 2022 covered all major anxiety disorder types and noted that effective treatment exists for all of them.

What causes anxiety disorders?

A combination of genetic predisposition, neurobiological factors, cognitive patterns and environmental experience is the most accurate answer. Someone whose nervous system is wired to overestimate threat and underestimate their own capacity to cope is at higher risk. Early trauma and prolonged stressful experiences can sensitise the threat-response system so that it activates more readily and is harder to calm.

In the Middle East and North Africa, years of political instability, conflict, displacement and economic pressure have created conditions where anxiety disorders are unsurprising. A nervous system that has been under sustained threat for years does not easily return to a calm baseline. This does not make the anxiety less treatable, but it does mean that treatment needs to acknowledge the real pressures of the person's life rather than treating the disorder as if it exists in a vacuum.

Several medical conditions can produce symptoms that mimic anxiety or worsen existing anxiety: overactive thyroid, heart rhythm disorders, caffeine excess and certain medications including steroids. This is why a basic medical assessment is appropriate before attributing physical symptoms to anxiety alone, particularly when the pattern is new or atypical.

What treatments work for anxiety disorders?

Cognitive behavioural therapy (CBT) is the most evidence-based psychological treatment for anxiety disorders. A meta-analysis published in Current Psychiatry Reports in 2023 confirmed its strong effectiveness across all major anxiety disorder types compared with waiting list controls and other treatments. The core of CBT for anxiety involves challenging overestimated threat appraisals and then practising gradual, planned exposure to feared situations rather than continuing to avoid them.

Medications, particularly SSRIs and SNRIs, are effective for anxiety disorders and are the pharmacological treatments recommended in most clinical guidelines. A comprehensive review published in Dialogues in Clinical Neuroscience in 2017 confirmed that combining medication with CBT produces better outcomes than either treatment alone in moderate to severe cases. Benzodiazepines such as diazepam provide fast symptom relief but do not address the underlying disorder, create dependence with regular use and are not recommended as a long-term treatment for anxiety. They are widely sold without prescription in parts of the region, which is a significant problem.

Lifestyle factors that are genuinely helpful include regular physical activity, reducing caffeine, consistent sleep and building gradual tolerance to uncertainty rather than seeking constant reassurance. These are supportive measures and not alternatives to treatment in moderate or severe anxiety, but they reduce the overall load on a nervous system that is already working too hard.

Why does avoidance make anxiety worse, not better?

Avoiding what frightens you produces immediate relief, and that relief is real. The problem is what it teaches the brain: that the avoided situation was genuinely dangerous and that you could not have handled it. This confirmation makes the fear stronger and the range of avoided situations wider. Over months and years, avoidance progressively narrows the life of someone with untreated anxiety.

Effective treatment does the opposite. Gradual, planned exposure to feared situations, managed carefully so that the person stays in the situation long enough for the anxiety to reduce on its own, teaches the nervous system that the threat was overestimated and the fear tolerable. This is uncomfortable to do and should be guided by a trained therapist, but it produces the lasting change in the anxiety mechanism that avoidance never will.

Some avoidance behaviours are less obvious: looking up symptoms repeatedly to check for a feared illness, seeking constant reassurance from family or doctors, or always carrying a benzodiazepine and checking it is there even without taking it. These are called safety behaviours and they maintain anxiety by preventing the learning that comes from tolerating uncertainty. Recognising them is part of the CBT process.

What if no specialist is nearby?

Primary care is always the right starting point. A well-informed general practitioner can diagnose anxiety disorders, initiate appropriate medication if indicated, and provide basic psychoeducation about how anxiety works. Simply understanding that the physical symptoms have an anxiety basis and that avoidance maintains the problem is itself therapeutic and changes how people respond to their symptoms.

Digital CBT delivered through structured online programmes or apps has a growing evidence base. A randomised controlled trial published in Depression and Anxiety in 2020 confirmed the effectiveness of digital CBT for moderate to severe generalised anxiety disorder. For someone in a rural area, a displacement context or a country where mental health services are minimal, a structured digital programme is meaningfully better than nothing.

The WHO mental health Gap Action Programme (mhGAP) trains primary care and general health workers in the detection and basic management of anxiety disorders specifically for low and middle income settings. If you are in an area served by international health NGOs, it is worth asking whether this programme or an equivalent is available, because it has been implemented across conflict-affected parts of the Arab world.

When does anxiety need emergency attention?

Go to an emergency department immediately if you have new, undiagnosed chest pain, even if you think it might be anxiety. Ruling out a cardiac cause requires investigation, not a best guess. Never assume chest pain is anxiety just because you have an anxiety history.

See a doctor urgently if anxiety is preventing you from working, leaving home or caring for dependants, or if you are increasingly avoiding situations in a way that is progressively narrowing your life. This is not a personality difficulty to push through alone. It is a treatable disorder, and earlier treatment produces faster and more complete recovery.

Seek immediate help if anxiety is accompanied by thoughts of self-harm, or if you are using alcohol or unprescribed sedatives to manage anxiety symptoms. These are signs that the condition has escalated beyond what self-management can address.

Sources

• Szuhany KL, Simon NM: Anxiety Disorders: A Review, JAMA, 2022
• Aletaha R, Kolahi AA, Mousavi Z et al: Anxiety disorders in the Middle East and North Africa region; 1990 to 2021, Acta neuropsychiatrica, 2025
• Bhattacharya S, Goicoechea C, Heshmati S et al: Efficacy of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Meta-Analysis of Recent Literature, Current psychiatry reports, 2023
• Bandelow B, Michaelis S, Wedekind D et al: Treatment of anxiety disorders, Dialogues in clinical neuroscience, 2017
• Fleet RP, Dupuis G, Marchand A et al: Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition, The American journal of medicine, 1996
• Eid M, Abi Kheir V, Bizri M et al: Somatic symptom and related disorders in the Arab world: a narrative review of clinical features and care implications, Frontiers in psychiatry, 2025