High functioning anxiety: signs and what to do about it

Have you ever felt a wave of terror wash over you when someone asked for your opinion in a meeting?

Or avoided talking to someone because every time you tried your mouth got dry and you couldn’t find the words? Or lost sleep because you couldn’t turn down the racing thoughts in your mind?

If you find yourself in similar situations frequently, but you are still generally functioning at a pretty high level in your day-to-day life, you may be living with a condition commonly called “high functioning anxiety.”

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The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) is the most commonly used guide to the diagnosis of mental illness in psychiatry. 

You might be surprised to learn that the DSM-5 does not include an official mental health diagnosis for “high-functioning anxiety.”  Instead, it is an informal term to describe symptoms of anxiety that might not rise to the level of being a diagnosable anxiety disorder. Or, it can describe people with diagnosable anxiety disorders who are otherwise functioning at a high level in their daily lives.

The 2019 National Health Interview Survey found that 15% of adults surveyed reported experiencing anxiety symptoms in the past two weeks (Terlizzi, 2020).

Anxiety disorders are some of the most commonly diagnosed psychiatric disorders. Women are twice as likely as men to experience them. Non-Hispanic white adults were the most likely to report symptoms, but all races are susceptible (Chand, 2020).

The symptoms of anxiety are unique to each person, but science has found that there are many common threads. Symptoms have been categorized as cognitive, physiological, behavioral, and affective (mood). If you have anxiety, you may experience some of these symptoms (Chand, 2020).

Cognitive symptoms

These symptoms can include (Chand, 2020):

• Fear of injury or death

• Fear of negative opinion of others

• Fear of losing control or “going crazy”

• Frightening thoughts or memories

• Overthinking

• Trouble concentrating

• Poor memory

• Excessive worry about potential threats

• Confusion 

Physical symptoms

You may experience some physical symptoms, including (Chand, 2020):

• Increased heart rate

• Rapid breathing

• Feeling like you have trouble breathing

• Feeling lightheaded

• Heart palpitations

• Trouble swallowing

• Chest pain or pressure

• Feeling sweaty

• Upset stomach

• Nausea or diarrhea

• Hot or cold flashes

• Shaking

• Feeling numb

Behavioral symptoms

These can include (Chand, 2020): 

• Feeling restless or agitated

• Pacing

• Hyperventilating

• Freezing up

• Avoiding situations that may provoke anxiety

• Feeling the need to escape or run away

• Trouble speaking

• Needing repeated reassurance

Affective symptoms

Affective symptoms are mood-related symptoms that can include (Chand, 2020): 

• Feeling nervous, tense, or “wound up”

• Feeling frightened or terrified

• Feeling jumpy

• Feeling overly impatient or frustrated

Risk factors for developing an anxiety disorder

It's impossible to predict exactly who will or won’t struggle with an anxiety disorder at some point in their lives. The following risk factors have been shown to increase the risk of developing an anxiety disorder (Blanco, 2014):

• Female gender

• Family history of major depression

• Disturbed family environment

• Childhood abuse

• Low self-esteem

• Lower educational attainment 

Researchers have attempted for years to determine if there are objective biomarkers such as brain structure or genetic markers to help predict who will be affected by an anxiety disorder. Most studies have produced results that couldn’t be replicated, but research is ongoing (Maron, 2017).

How are anxiety disorders diagnosed?

As previously mentioned, the DSM-5 is the gold standard for criteria to diagnose mental health disorders. There are nine separate anxiety disorders defined in the DSM-5. Your mental health provider will compare your reported anxiety symptoms to the definitions in the DSM-5 to see if you meet the criteria for a particular form of anxiety.

For example, the criteria for diagnosing generalized anxiety disorder are (Reynolds, n.d.):

• Excessive anxiety or worry that occurs more days than not for at least 6 months

• Difficulty controlling the anxiety

• The anxiety is associated with at least three of the following symptoms: restlessness, feeling easily fatigued, trouble concentrating, irritability, muscle tension, sleep disturbances

• The symptoms are causing distress or difficulty functioning

• The symptoms aren’t caused by substance use or a medical condition

• The symptoms aren’t better explained by another mental health disorder

Many people with high functioning anxiety try to manage their symptoms on their own, but it can be especially helpful to seek help. Having a diagnosis can make you eligible for certain treatments and services with your insurance company and can help guide which treatments might be most beneficial.

Anxiety disorders have a very high chance of happening alongside other mental and physical disorders. Often, people need to address both their anxiety and these other illnesses to improve their quality of life.

Depression

Individuals with high anxiety traits have been found to be potentially more vulnerable to depression. This is thought to be because increased anxiety contributes to greater vulnerability to stress. Over time, this can contribute to the development of depression (Weger, 2018).

Substance abuse

Decades of psychiatric research have shown that anxiety disorders and substance abuse disorders occur more often together than can be explained by chance. Researchers have concluded that when a person experiences anxiety or substance abuse, they are at risk for the other to develop (Smith, 2008). 

Eating disorders

An Australian study of 152 women presenting for either eating disorder treatment or anxiety disorder treatment found a significant overlap between the two conditions. 65% of the women getting treatment for an eating disorder also met the criteria for an anxiety disorder. The majority of these (69%) reported that the anxiety disorder symptoms began before the start of their eating disorder (Swinbourne, 2012).

Physical illness

Physical ailments and anxiety are another area where two conditions influence each other. People who have a diagnosis of depression or an anxiety disorder report more than double the rate of chronic medical illness compared to those without depression or anxiety. Being diagnosed with a chronic medical condition also significantly increases the risk of being diagnosed with anxiety or depression (Hirschfeld, 2001).

Due to their prevalence, anxiety disorders have been fairly well-studied, and effective treatments for anxiety are available. 

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a type of psychotherapy that helps participants recognize negative thoughts and behaviors that are causing them stress and replace them with thoughts and behaviors that help them deal with problems in a more positive way (Borza, 2017).

Studies have shown CBT to be very effective for a wide variety of mental health conditions including anxiety. Participants with anxiety have reported improvements in symptoms and quality of life (Kaczkurkin, 2015).

Medication

Many people struggling with anxiety may benefit from trying medication to help manage symptoms. First-line treatments are usually a class of medication called “selective serotonin reuptake inhibitors,” otherwise known as SSRIs or antidepressants. These medications increase the amount of serotonin that is available in the brain, allowing for improved mood regulation (Bandelow, 2017).

Other medications may be considered by your healthcare provider based on your individual health history and experiences with anxiety.

Lifestyle changes

There are many self-care, complementary, and alternative treatments that have been touted to help reduce anxiety. The evidence to support these interventions varies significantly. 

Mindfulness techniques have shown similar effectiveness as CBT. Most supplements do not have sufficient evidence to support their use and may have significant side effects. There is some evidence that music therapy, aromatherapy, acupuncture, and massage are helpful for anxiety associated with specific diseases, but they have not been studied specifically with anxiety disorders (Locke, 2015).

Although the exact reason it works is not known, physical activity has shown great promise in reducing the amount of anxiety reported by participants. The exact type and amount of exercise needed to benefit will vary from person to person (Kandola, 2018).

Most people suffering from high functioning anxiety will benefit from a combination of strategies that help them address the unique roots of their anxiety. Your mental health professional can help you find out what treatments work best for you to increase your wellness.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

April 14, 2021

Written by

Ellyn Vohnoutka, BSN, RN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.