The dentist appointment is on Thursday, and it is Monday. You have been sleeping worse since Sunday. In the shower you go over everything that could go wrong, in the afternoon you imagine the sound of the drill and at night you work out how much it is going to hurt. When Thursday finally comes, the appointment lasts twenty minutes and is far less awful than the three days you spent living it in advance.

There is a name for this: anticipatory anxiety. This guide explains what it is, how it shows, why uncertainty triggers it, how it differs from fear, when it stops being normal, how to manage it and which test can help you see whether there is an anxiety problem behind it.

What is anticipatory anxiety?

In a review of uncertainty and anticipation in anxiety, the researchers Grupe and Nitschke define anxiety precisely as the emotional, mental and behavioural changes that happen in response to uncertainty about a possible future threat. Not knowing whether something bad will happen, or when, or how serious it will be, makes it impossible to prepare for it or avoid it, and that is what produces anxiety.

The difference from fear is useful. According to the research the same authors bring together, fear is a short-lived response to a specific threat in front of you, such as a dog barking at you. Anxiety, by contrast, is a sustained response to threats that are unpredictable or have not arrived yet. Anticipatory anxiety is therefore the most recognisable face of anxiety: the part that comes beforehand.

It is not a diagnosis in itself. It appears in almost every anxiety problem, each with its own focus: fear of having another attack in panic disorder, fear of embarrassing yourself in social anxiety, or worry about many things at once in generalised anxiety.

Symptoms of anticipatory anxiety

The symptoms of anticipatory anxiety are those of anxiety, but centred on something that has not happened yet:

  • In your head: going over and over what could go wrong, imagining the worst-case scenario, being unable to stop worrying and feeling that something awful is going to happen.
  • In your body: tension in the jaw or shoulders, stomach discomfort, palpitations, difficulty relaxing and trouble sleeping or waking up in the early hours turning things over.
  • In what you do: cancelling plans, putting off decisions or tasks, avoiding situations or asking others to reassure you that everything will be fine.

Many of these symptoms are, almost word for word, questions in the MyPsicoTest anxiety test, which we discuss below.

Why uncertainty triggers it

Grupe and Nitschke propose five processes that, in normal amounts, help us prepare for an uncertain threat and that become unbalanced in anxiety:

  1. Overestimating the threat: judging that bad things are more likely and more serious than they are.
  2. Hypervigilance: watching out for any sign of danger.
  3. Difficulty learning that something is safe, even when it keeps happening without consequences.
  4. Avoidance, both of situations and of thoughts themselves.
  5. An exaggerated reaction to uncertainty, which feels intolerable.

That last point has a name in psychology: intolerance of uncertainty. A meta-analysis by Miller and McGuire of 28 clinical trials notes that it contributes to the onset and maintenance of anxiety disorders, and found that psychological treatments reduce it substantially. Moreover, the more intolerance of uncertainty improved, the more anxiety symptoms improved.

Avoidance brings relief today and fuels anxiety tomorrow

Cancelling the appointment or not getting on the plane brings instant calm. But, as the same authors point out, avoidance is one of the processes that keep anxiety going: if you never check that the situation was bearable, your brain cannot learn that it was.

When anticipatory anxiety shows up

Before a panic attack: the fear of fear

The WHO describes panic disorder as panic attacks plus the fear of having more of them. That fear is anticipatory anxiety in its purest form, and it is often what limits people most: it leads them to avoid public transport, crowded places or anywhere it has happened before. We explain what happens during an attack in Panic attack: what it is, why it feels like a heart attack and what to do.

Before social situations

In social anxiety, the distress often starts days in advance: rehearsing what you will say, imagining your mind going blank, thinking about how people will see you. If that sounds familiar, the Social Anxiety Test can guide you, and Fear of public speaking: why you freeze and when it is social anxiety may help.

Before medical tests

Here there is an interesting nuance. A review by Goodwin and colleagues, covering 74 studies and almost 120,000 participants, found that anxiety about a possible cancer diagnosis was often linked to having more screening tests, whereas fear of the test itself was linked to having fewer. Anticipation is not always bad: sometimes it pushes you to look after yourself, and sometimes it freezes you.

Woman sitting in a waiting room looking anxiously at the doctor approaching with a report, a moment of anticipatory anxiety before a medical test

When it stops being normal

A few nerves before something important are normal and even useful. The WHO explains that in anxiety disorders, fear and worry are intense and excessive, hard to control and very distressing; they usually last for months and lead people to avoid the situations that trigger them. It is worth paying attention if:

  • The anxiety starts days or weeks before every event.
  • It makes you give up important things: trips, jobs, medical tests or plans.
  • You often sleep badly because of what might happen.
  • It is not limited to one situation; you jump from one worry to the next.

Is there an anticipatory anxiety test?

There is no specific anticipatory anxiety test, because it is not a diagnosis but a form of anxiety that appears in many different problems. What we do have at MyPsicoTest is the Anxiety Test, which picks up several of its signs. One of its statements is: "I have felt afraid, as if something awful might happen." Another: "I have put off decisions or tasks, or cancelled plans, out of fear or nervousness." There are 14 questions about the last two weeks, based on the GAD-7 questionnaire, answered in about four minutes according to how often each applies and grouped into three areas:

  • Worry and mental tension: being unable to stop worrying, fear that something awful will happen, or irritability.
  • Physical symptoms: tension, palpitations, restlessness or sleep problems.
  • Avoidance and interference: avoiding situations, cancelling plans or anxiety affecting your work or relationships.

The score ranges from 0 to 42 and falls into four bands. You do not need to sign up, and your answers are not sent to any server. If your anticipation centres mainly on other people, try the social anxiety test too. All the questionnaires, free and anonymous, are in the psychological tests catalogue.

How to manage anticipatory anxiety

The WHO points out that the psychological interventions with the most evidence for anxiety disorders are based on cognitive behavioural therapy, including exposure, in which people learn to face their fears. Some tools you can start trying:

  • A fixed worry time. In a trial by McGowan and Behar with 53 people who worried a lot, setting aside 30 minutes every day, at the same time and in the same place, for worrying, and postponing the worries that cropped up until then, reduced worry, anxiety and insomnia over two weeks more than in the comparison group.
  • Separate what is up to you. If there is something you can prepare, prepare it; if not, note it down for your worry time.
  • Do not get off the plane. Avoiding brings relief today and fuels anxiety tomorrow. If it is hard, start with small steps.
  • Come back to the present. Slow breathing or noticing what is around you can help you step out of the loop of future scenarios. If you spend the day turning things over, we explain why it is so hard to stop in Overthinking: why you cannot stop turning things over.
  • Check what actually happened. Writing down what you feared and what really happened can help you correct the tendency to overestimate the threat.

If anticipatory anxiety makes you give up things that matter to you, therapy is the route with the most evidence behind it. At the end of the test you will find our recommendation of a licensed psychologist who works with anxiety and depression, online too.

If your result worries you or you want a professional assessment, you can talk to Xènia Capel Salcedo, a licensed psychologist (COPC reg. 14982), who offers a free first consultation call and online therapy from anywhere.

MyPsicoTest team · Updated: