Defining Anxiety
The difference between normal anxiety and an anxiety disorder is that anxiety disorders cause such severe distress as to interfere with someone’s ability to lead a normal life. “Anxiety disorder” refers to any of a number of specific disorders, including generalized anxiety disorder, phobia, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety disorder.
- feelings of panic, fear, or uneasiness
- uncontrollable and obsessive thoughts
- flashbacks to traumatic events
- problems sleeping
- nightmares
- shortness of breath
- nausea
- muscle tension
- dizziness
- heart palpitations
- dry mouth
- cold or sweaty hands
Etiology
Anxiety in and of itself is not a bad thing. In fact, the hormonal response involved in anxiety evolved to help humans react to danger—it better prepares them to recognize threats and to act accordingly to ensure their safety. Such sensory information is processed by the amygdala, which communicates information about potential threats to the rest of the brain. However, anxiety becomes counterproductive and thus is deemed “disordered” when it is experienced with such intensity that it impedes social functioning.
Anxiety disorders develop as the result of the interaction of genetic (inherited) and environmental factors. Neurologically speaking, increased amygdala reactivity is correlated with increased fear and anxiety responses. Low levels of GABA (a neurotransmitter in the brain that reduces central nervous system activity) can contribute to anxiety, and serotonin, glutamate, and the 5-Ht2A receptor have also all been implicated in the development of anxiety disorders.
In addition to biological factors, anxiety disorders can also be caused by various life stresses, such as financial worries or chronic physical illness. Severe anxiety and depression can also be induced by sustained alcohol abuse; with prolonged sobriety these symptoms usually decrease. Even moderate sustained alcohol use may increase anxiety and depression levels in some individuals. Caffeine, alcohol, and benzodiazepine dependence can worsen or cause anxiety and panic attacks.
Treatment
Treatment options for anxiety disorders include lifestyle changes, therapy, and medication. The most common intervention is cognitive behavioral therapy (CBT), which aims to help the person identify and challenge their negative thoughts (cognitions) and change their reactions to anxiety-provoking situations (behaviors).
In terms of medication, SSRIs are most commonly recommended. Benzodiazepines are also sometimes indicated for short-term or “as-needed” use. MAOIs such as phenelzine and tranylcypromine are also considered effective and are especially useful in treatment-resistant cases, but dietary restrictions and medical interactions may limit their use.
I. Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by chronic anxiety that is excessive, uncontrollable, often irrational, and disproportionate to the actual object of concern. People with GAD often characterize it as a feeling of “free-floating anxiety”—a term that Sigmund Freud used in his early work. Typically, the anxiety has no definite trigger or starting point, and as soon as the individual resolves one issue or source of worry another worry arises. People with GAD also tend to catastrophize, meaning they may assume the absolute worst in anxiety-inducing situations. Racing thoughts, inability to concentrate, and inability to focus are also characteristic of GAD.
GAD is a particularly difficult disorder to live with; because the individual’s anxiety is not tied to a specific situation or event, they experience little relief. This disorder can contribute to problems with sleep, work, and daily responsibilities and often impacts close relationships.
Generalized anxiety disorder (GAD) is characterized by chronic anxiety that is excessive, uncontrollable, often irrational, and disproportionate to the actual object of concern. People with GAD often characterize it as a feeling of “free-floating anxiety”—a term that Sigmund Freud used in his early work. Typically, the anxiety has no definite trigger or starting point, and as soon as the individual resolves one issue or source of worry another worry arises. People with GAD also tend to catastrophize, meaning they may assume the absolute worst in anxiety-inducing situations. Racing thoughts, inability to concentrate, and inability to focus are also characteristic of GAD.
GAD is a particularly difficult disorder to live with; because the individual’s anxiety is not tied to a specific situation or event, they experience little relief. This disorder can contribute to problems with sleep, work, and daily responsibilities and often impacts close relationships.
DSM-5 Diagnostic Criteria
In order for GAD to be diagnosed, a person must experience excessive anxiety and worry—more days than not—for at least 6 months and about a number of events or activities (such as work or school performance). This excessive worry must interfere with some aspect of life, such as social, occupational, or daily functioning, and the person must have trouble controlling the anxiety. The disturbance must not be attributed to the physiological effects of a substance (e.g., a drug or medication) or another medical condition, and must not be better explained by another medical disorder. At least 3 of the following symptoms must be experienced: restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and/or sleep disturbance.
Etiology
In any given year, approximately 2.3% of American adults and 2% of European adults experience GAD. Although there have been few investigations into the disorder’s heritability, a summary of available family and twin studies suggests that genetic factors play a moderate role in its development (Hettema et al., 2001). Specifically, about 30% of the variance for generalized anxiety disorder can been attributed to genes. Individuals with a genetic predisposition for GAD are more likely to develop the disorder, especially in response to a life stressor.
Cognitive theories of GAD suggest that worry represents a mental strategy to avoid more powerful negative emotions (Aikins & Craske, 2001), perhaps stemming from earlier unpleasant or traumatic experiences. Indeed, one longitudinal study found that childhood maltreatment was strongly related to the development of this disorder during adulthood (Moffitt et al., 2007). According to these theories, generalized anxiety may serve as a distraction from remembering painful childhood experiences.
Long-term use of benzodiazepines can worsen underlying anxiety, with evidence that reduction in benzodiazepine use can in turn lead to a lessening of anxiety symptoms. Similarly, long-term alcohol use is associated with the development of anxiety disorders, with evidence that prolonged abstinence can in turn result in the remission of anxiety symptoms.
Treatment
GAD is generally chronic, but it can be managed, or even eliminated, with the proper treatment. While there are many options for treating GAD, full recovery is only seen about 50% of the time, which indicates the need for further research into more effective treatment options.
Pharmaceutical treatments for GAD include selective serotonin reuptake inhibitors (SSRIs), which are more commonly used as antidepressants. SSRIs block the reabsorption of serotonin in the brain so that it can keep activating serotonin receptors, improving the individual’s mood.
II. Panic Disorder and Panic Attacks
People with panic disorder experience recurrent (more than one) and unexpected panic attacks, along with at least one month of persistent concern about additional panic attacks, worry over the consequences of the attacks, or self-defeating changes in behavior related to the attacks (such as withdrawing from social activities out of fear of having an attack) (APA, 2013). Since panic attacks can occur unexpectedly, they can become a cause of ongoing worry and avoidance. People with panic disorder may become so afraid of having panic attacks that they experience what are known as anticipatory attacks—essentially panicking about potential panic attacks and entering a cycle of living in fear of fear.
Panic disorder is very treatable; however, left untreated, it can significantly reduce quality of life. People with untreated panic disorder are at an increased risk for specific phobias, such as agoraphobia (a fear of leaving the house), and they often suffer from one or more additional mental-health conditions, such as depression or substance abuse.
DSM-5 Diagnostic Criteria
In the DSM-5, panic attacks themselves are not mental disorders; instead, they are listed as specifiers for other mental disorders, such as anxiety disorders. Panic attacks are differentiated as being either expected or unexpected; the categories from the previous DSM-IV-TR (situationally bound/cued, situationally predisposed, or unexpected/uncued) have been removed.
In order to be diagnosed with panic disorder, a person must experience unexpected, recurrent panic attacks. These panic attacks must also be accompanied by at least one month of a significant and related behavior change in relation to the attacks, a persistent concern or fear of more attacks, or a worry about the attacks’ consequences. As is the case with other anxiety disorders, the panic attacks cannot result from the physiological effects of drugs and other substances, a medical condition, or another mental disorder. While the previous version of the DSM defined panic disorder as occurring either with or without agoraphobia, the new DSM-5 lists panic disorder and agoraphobia as two distinct disorders.
The heart of the anxiety in social anxiety disorder is the person’s concern that they may act in a humiliating or embarrassing way, such as appearing foolish, showing symptoms of anxiety (such as blushing), or doing or saying something that might lead to rejection (such as offending others). The kinds of social situations that may cause distress include public speaking, having a conversation, meeting strangers, eating in restaurants, or using public restrooms. Although many people become anxious in social situations like public speaking, the fear, anxiety, and avoidance experienced in social anxiety disorder are highly distressing and lead to serious impairments in life.
Physical symptoms often accompanying social anxiety disorder include excessive blushing, excessive sweating, trembling, palpitations, and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001); more likely to perform poorly at work and to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011); and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).
When people with social anxiety disorder are unable to avoid situations that provoke anxiety, they typically perform safety behaviors: mental or behavioral acts that reduce anxiety in social situations by reducing the chance of negative social outcomes. Safety behaviors can include avoiding eye contact, rehearsing sentences before speaking, talking only briefly, and not talking about oneself (Alden & Bieling, 1998). Although these behaviors are intended to prevent the person with social anxiety disorder from doing something awkward that might draw criticism, these actions often exacerbate the problem because they do not allow the individual to disconfirm their negative beliefs, often eliciting rejection and other negative reactions from others (Alden & Bieling, 1998).
One of the most well-established risk factors for developing social anxiety disorder is behavioral inhibition (Clauss & Blackford, 2012). Behavioral inhibition is thought to be an inherited trait, and it is characterized by a consistent tendency to show fear and restraint when presented with unfamiliar people or situations (Kagan, Reznick, & Snidman, 1988). A recent statistical review of studies demonstrated that behavioral inhibition was associated with a greater-than sevenfold increase in the risk of development of social anxiety disorder, indicating that behavioral inhibition is a major risk factor for the disorder (Clauss & Blackford, 2012).
IV. Specific PhobiaA person diagnosed with a specific phobia (formerly known as a “simple phobia”) experiences excessive, distressing, and persistent fear or anxiety about a specific object or situation (such as animals, enclosed spaces, elevators, or flying) (APA, 2013). Even though people realize their level of fear and anxiety in relation to the phobic stimulus is irrational, some people with a specific phobia may go to great lengths to avoid the phobic stimulus (the object or situation that triggers the fear and anxiety).
A panic attack is defined as a period of extreme fear or discomfort that develops abruptly and reaches a peak within 10 minutes. Its symptoms include accelerated heart rate, sweating, trembling, choking sensations, hot flashes or chills, dizziness or lightheadedness, fears of losing control or going crazy, and fears of dying (APA, 2013). Sometimes panic attacks are expected, occurring in response to specific environmental triggers (such as being in a tunnel); other times, these episodes are unexpected and emerge randomly (such as when relaxing).
People with panic disorder experience recurrent (more than one) and unexpected panic attacks, along with at least one month of persistent concern about additional panic attacks, worry over the consequences of the attacks, or self-defeating changes in behavior related to the attacks (such as withdrawing from social activities out of fear of having an attack) (APA, 2013). Since panic attacks can occur unexpectedly, they can become a cause of ongoing worry and avoidance. People with panic disorder may become so afraid of having panic attacks that they experience what are known as anticipatory attacks—essentially panicking about potential panic attacks and entering a cycle of living in fear of fear.
Panic disorder is very treatable; however, left untreated, it can significantly reduce quality of life. People with untreated panic disorder are at an increased risk for specific phobias, such as agoraphobia (a fear of leaving the house), and they often suffer from one or more additional mental-health conditions, such as depression or substance abuse.
DSM-5 Diagnostic Criteria
In the DSM-5, panic attacks themselves are not mental disorders; instead, they are listed as specifiers for other mental disorders, such as anxiety disorders. Panic attacks are differentiated as being either expected or unexpected; the categories from the previous DSM-IV-TR (situationally bound/cued, situationally predisposed, or unexpected/uncued) have been removed.
In order to be diagnosed with panic disorder, a person must experience unexpected, recurrent panic attacks. These panic attacks must also be accompanied by at least one month of a significant and related behavior change in relation to the attacks, a persistent concern or fear of more attacks, or a worry about the attacks’ consequences. As is the case with other anxiety disorders, the panic attacks cannot result from the physiological effects of drugs and other substances, a medical condition, or another mental disorder. While the previous version of the DSM defined panic disorder as occurring either with or without agoraphobia, the new DSM-5 lists panic disorder and agoraphobia as two distinct disorders.
III. Social Anxiety Disorder (Social Phobia)
Social anxiety disorder (formerly called social phobia) is characterized by extreme and persistent fear or anxiety and avoidance of social situations in which the person could potentially be evaluated negatively by others (APA, 2013). As with specific phobias, social anxiety disorder is common in the United States; a little over 12% of all Americans experience social anxiety disorder during their lifetime (Kessler et al., 2005).Physical symptoms often accompanying social anxiety disorder include excessive blushing, excessive sweating, trembling, palpitations, and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001); more likely to perform poorly at work and to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011); and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).
When confronted with the object of their phobia, a person will generally enter a state of panic and experience a wide variety of physical symptoms, such as nausea, increased heartbeat, dizziness, and sweaty palms. For this reason, many people with phobias simply avoid the object of their phobia. Such avoidance can range from not wanting to be outside in a lightning storm to being unable to even look at a picture of lightning.
There are five general categories of phobias:
There are five general categories of phobias:
- Environment phobias (e.g., fear of lightning, fear of tornadoes)
- Animal phobias (e.g., fear of snakes, fear of bears)
- Blood-injury phobias, (e.g., fear of getting a shot, fear of the sight of blood)
- Situational phobias (e.g., fear of heights, fear of public speaking)
- Other phobias not otherwise specified (e.g., fear of vomiting)
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