MacArthur SES & Health Network
MacArthur SES & Health Network

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This summary was prepared by Ralf Schwarzer of the Freie Universitöt, Berlin, Germany for the Psychosocial Working Group. Last revised December, 1997.

Chapter Contents

  1. Definition
  2. Measurement
  3. Relation to SES
  4. Relation to Health
  5. References


Anxiety research is conducted within two separate traditions: (a) as an acute emotion and as a personality construct, and (b) as a mental disorder or an illness. The first line of research is mainly done by psychologists based on psychometric tools with a major focus on individual differences. The second line of research is mainly done by psychiatrists based on qualitative categories (such as given by the DSM) with a focus on case studies. The leading periodical in the first tradition is "Anxiety, Stress, and Coping: An International Journal," whereas the leading periodical in the second tradition is the "Journal of Anxiety Disorders." The statements by the present author are biased in favor of the psychological approach.

A distinction between state and trait anxiety has become commonplace (Spielberger, 1972, 1983). State anxiety is defined as an unpleasant emotional arousal in face of threatening demands or dangers. A cognitive appraisal of threat is a prerequisite for the experience of this emotion (Lazarus, 1991). Trait anxiety, on the other hand, reflects the existence of stable individual differences in the tendency to respond with state anxiety in the anticipation of threatening situations.

Moreover, at the level of both state and trait anxiety, a further distinction has been made between worry and emotionality (Spielberger, 1980). Worry refers to the cognitive component of the anxiety experience. Individuals respond to threat with worries about the imminent danger and their perceived lack of competence to counteract the threat. Emotionality, on the other hand, refers to the perceived arousal component of the anxiety experience. Individuals experience sweating, headache, nervosity, and other bodily reactions. Although these two components are usually present at the same time to some degree, they are only poorly to moderately related with each other. Moreover, they differ in terms of their behavioral consequences. Worry is substantially related to performance impairment whereas emotionality is almost unrelated to it.

Worry is negatively correlated (r ˜.50) with perceived self-efficacy (Schwarzer, 1996). Individuals who do not feel competent to cope with challenging demands, harbor self-doubts and worry. Thus, they are more anxious.

Depression is more prevalent in anxious individuals (r ˜.50). However, the construct of depression is clearly distinct from the construct of anxiety, since the latter is a response to perceived threat whereas the former is a response to perceived harm or loss (Lazarus, 1991).

A stress response may include anxiety but not necessarily so (Endler, 1997). Stress is commonly understood in one of three ways: (a) as a stimulus such as a critical event (e.g., a "stressor"), (b) as a response to such an event (symptoms), and (c) as a transactional encounter between a person and a situation. According to the first view, anxiety follows the critical event (e.g., in the form of a post-traumatic disorder; Keane, Taylor, & Penk, 1997). According to the second view, anxiety is part of the response pattern. According to the third view, anxiety is an accompanying emotion.

Due to the many different conceptualizations of anxiety, it does not come as a surprise to find several thousand publications that seem to contradict each other.

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Among many instruments to assess anxiety, one stands out: the State-Trait Anxiety Inventory (STAI, Spielberger, 1983). This does not mean that it is an ideal measure but it is the most frequently used scale in research world-wide, and no other measure has received as many foreign language adaptations and citations in the last three decades. Thus, it is the standard in the field. The self-report inventory consists of 20 items to assess state anxiety, and another 20 items to assess trait anxiety. These two parts differ in the item wording, in the response format (intensity vs. frequency), and in the instructions for how to respond. An alternative to the STAI is the Endler Multidimensional Anxiety Scales (EMAS; Endler, Edwards, & Vitelli, 199 1), based on Endler's theory of person-situation interactionism (cf. Endler, 1997).

Relation to SES

Trait anxiety is on average higher among lower social class individuals than among middle class individuals (Lewis, 1996; Lenzi et al., 1993; Zeidner, 1988).

Relation to Health

Trait anxiety has been found related to health. For example, individuals whose self-rating of health is favorable, score lower in anxiety ( Forsberg & Bjorvell, 1993). However, the association between these two variables is much more complex. Anxiety can be the cause of illness, or anxiety can be an effect of illness.

(a) Anxiety as an independent variable

Individuals with high levels of anxiety are predisposed to a number of ailments. This is usually labelled "somatization." Anxiety results, for example, in tension headache, dyspepsia, peptic ulcers, hypertension, etc.

In addition to somatization, another effect of anxiety is health risk behavior. Anxious individuals delay health care seeking, they avoid screenings that might produce unfavorable or threatening information. This is the case, for example, in HIV testing or mammography screenings.

A third effect of anxiety lies in self-reports of ill health. Anxious individuals complain more frequently about ill health, they seek medical attention and put a strain on their social networks and on the health care system. For example, they report more symptoms allegedly due to dental amalgam fillings.

(b) Anxiety as a dependent variable

Anxiety is an accompanying emotion of stressful encounters. Stress leads to elevated levels of state anxiety and blood pressure, disposing patients, in turn, to worse conditions.

Stress can be represented by distinct "stressors" such as natural disasters, accidents, migration, divorce, unemployment, surgery, or disease. Following these events or conditions, persons develop patterns of emotional distress, including anxiety and depression. Anxiety following a myocardial infarct is an example (Dew et al., 1996; Frasure-Smith et al., 1995; Schwarzer & Schröder, 1997).

Such an emotional response of clinical significance is found, for example, in posttraumatic stress disorder (PTSD) after experiencing a severe trauma.

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(c) Anxiety as a mediator

After substantial and prolonged anxiety reactions are experienced, these can, in turn, cause adverse health effects. Thus, anxiety can be considered a mediator between stressful life events and ill health. Emotional reactions following stress may develop into a spiral of effects. Psychological interventions are needed to interrupt this deleterious process. Social support and professional help can buffer the effect and restabilize the person, so no physical health care will be necessary.

(d) Anxiety as a component of mental illness

Finally, specific kinds of anxiety constitute the key components in various manifestations of psychiatric morbidity, such as panic or anxiety disorders.

In sum, anxiety is related to ill health in a number of ways. Unfortunately, most of the research is correlational and cross-sectional which does not allow us to uncover the causal mechanisms involved in this relationship (Schwarzer, 1990, 1996).


Dew, M. et al. (1996). Prevalence and predictors of depression and anxiety-related disorders during the year after heart transplantation. Journal of Higher Education, 18 (6) 48S-61S.

Endler, N. S. (1997). Stress, anxiety, and coping: The multidimensional interaction model. Canadian Psychology, 38.

Endler, N. S., Edwards, J. M., & Vitelli, R. (1991). Endler Multidimensional Anxiety Scales (EMAS): Manual. Los Angeles, CA.: Western Psychological Services.

Forsberg, C., & Bjorvell, H. (I 993). Swedish population norms for the GHRI, HI and STAI-state. Quality of Life Research: An International Journal, 2 (5), 349-356.

Frasure-Smith, N., Lesperance, F., & Talojic, M. (I995). The impact of negative emotions on prognosis following myocardial infarction: Is it more than depression? Health Psychology, 14 (5) 388-398.

Kean, T., Taylor, K., & Penk, W. (1997). Differentiating post-traumatic stress disorder (PTSD) from major depression (MDD) and generalized anxiety disorders (GAD). Journal of AnxieLy Disorders, 11 (2) 317-328.

Lazarus, R. S. (I 991). Emotion and adaptation. London: Oxford University Press.

Lenzi, A., et al. (I 993). Social class and mood disorders: Clinical features. Social Psychiatry and Psvchiatric Epidemiology, 28 (2) 56-59.

Lewis, G. (I 996). Depression and public health. International Review of Psychiatry, 8 (4) 289-294.

Schwarzer, R. (I 990). Current trends in anxiety research. In P. J. D. Drenth, J. A. Sergeant, & R. J. Takens (Eds.), European Perspectives in Psychology. Vol. 2. (pp. 225-244.) Chichester, UK: John Wiley & Sons.

Schwarzer, R. (I 996). Thought control of action: Interfering self-doubts. In 1. G. Sarason, G. R. Pierce, & B. R. Sarason (Eds.), Cognitive interference: Theories, methods, and findings (pp. 99-115). Mahwah, NJ: Erlbaum.

Schwarzer, R., & Schröder, K. (1997). Effects of self-efficacy and social support on postsurgical recovery of heart patients. Irish Journal of Psychology, 18 (1), 88-103.

Spielberger, C. D. (1972). Anxiety: Current trends in theory and research: I. New York, N.Y.: Academic Press.

Spielberger, C. D. (1980). Test Anxiety Inventory. Preliminary professional manual. Palo Alto, CA: Consulting Psychologists Press.

Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI). PaloAlto, CA: Consulting Psychologists Press.

Zeidner, M. (1988). Health and demographic correlates of trait anxiety in Israeli adults. Anxiety Research, 1:(2) 127-135.

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