What is Anxiety?

Anxiety is a normal response to perceived threat. For this reason, anxiety serves an important purpose. In the presence of danger, anxiety starts a cascade of events that help to increase our chance of survival. When we see a poisonous snake, it would be wise to avoid it. Normally, the anxiety response turns off once the threat is removed. But in some individuals, the anxiety response does not turn off and remains constantly elevated or “out of proportion” to the threat. 

Experiencing anxiety on the battlefield or in an active war zone serves a very important survival role. But when this anxiety persists after returning home, it can be disruptive, tortuous, and debilitating.

The term “Anxiety” is sometimes used to describe temporary feelings of nervousness or fear in response to specific situations, thoughts, or events. For example, starting a new job, moving into a new home, giving a presentation, or thinking disturbing thoughts. Other times, “Anxiety” is used to describe more persistent feelings of worry, nervousness, or fear that occur without a trigger. 

Anxiety comes in many flavors. We organize anxiety symptoms into four general categories:

  1. Feelings
  2. Behaviors
  3. Thoughts
  4. Physical Symptoms

Below we provide basic information about the most common anxiety disorders. Please note that Obsessive Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) are considered anxiety disorders but are not reviewed here.

Medical Work Up For Anxiety Disorders

ConditionWork Up
Cardiac DiseaseElectrocardiogram
Asthma, COPDChest X-Ray; Pulmonary Function Tests
Thyroid DiseaseTSH w/ reflex Free T4
HypoglycemiaMetabolic Panel
PheochromocytomaUrine Testing
AnemiaCBC w/ Differential; Iron Studies (Ferritin, TIBC, Iron, Transferrin)
SeizuresElectroencephalogram (EEG); MRI
Substance Abuse (Stimulants, PCP, MDMA, Cannabis, Nicotine, Caffeine)Urine/Serum Toxicology; Inquire about drug use
Withdrawal States (Alcohol, Benzodiazepines, Opioids)Urine/Serum Toxicology; Inquire about drug use
Medication Side EffectsPseudoephedrine, Methylphenidate, Amphetamines, beta-agonists, Amantadine, Bromocriptine, L-dopa, Bupropion, Antipsychotics, Steroids, Meperidine, Metoclopramide, Oxybutinin, Meperidine, Benztropine, Theophylline, Indomethacin

Anxiety Diagnostic Algorithm

Anxiety Disorders

Generalized Anxiety Disorder

Generalized Anxiety Disorder is can be described as excessive anxiety and worry about a number of events or activities in a person’s life. The anxiety is persistent and is very difficult to control or stop. Individuals suffering with Generalized Anxiety Disorder “sweat the small stuff” and dwell on past experiences or worry about the future. Catastrophizing, or immediately thinking of the worst case scenario, is common. The anxiety and worry are usually associated with a feeling of restlessness, difficulty relaxing, feeling “tense” or “on edge”, tiredness, and irritability. In addition, individuals with generalized anxiety often report problems concentrating or falling sleep.

DSM-5 Criteria

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

  1. Restlessness or feeling keyed up or on edge.
  2. Being easily fatigued.
  3. Difficulty concentrating or mind going blank.
  4. Irritability.
  5. Muscle tension.
  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Treatment of Generalized Anxiety Disorder

The best treatment for Generalized Anxiety Disorder is a combination of therapy and medication. Some people don’t require medication and therapy is enough. Numerous research studies demonstrate that both therapy and medication together lead to better outcomes then either alone. The type of therapy and medication will depend on the individual and the experience of the mental health professional. 

Therapy

Cognitive Behavioral Therapy

Mindfulness Based Stress Reduction

Psychodynamic Psychotherapy

Medications

Selective Serotonin Reuptake Inhibitors (SSRIs):

FDA Approved: Escitalopram, Paroxetine 

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs):

FDA Approved: Venlafaxine, Duloxetine

Benzodiazepines

FDA Approved: Clonazepam (Klonopin)

Buspirone (Buspar)

Hydroxyzine (Vistaril)

Tricyclic Antidepressants (TCAs)

Monoamine Oxidase Inhibitors (MAOIs)

Anticonvulsant Mood Stabilizers (e.g., Valproic acid, Lamotrigine, Gabapentin, Pregabalin)

Separation Anxiety Disorder

Separation Anxiety Disorder, which typically occurs in children and adolescents, is a developmentally inappropriate fear or anxiety concerning separation from those to whom the individual is attached. The child often experiences recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures and/or persistent and excessive worry about losing major attachment figures. There is usually a reluctance or refusal to go out, go to school, be alone, or sleep away from home. There may also be repeated complaints of physical symptoms such as headaches, stomachaches, nausea, and/or vomiting when separation from major attachment figures occurs or is anticipated.

DSM-5 Criteria

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

  1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
  2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
  3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
  4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
  5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
  6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
  7. Repeated nightmares involving the theme of separation.
  8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder is characterized by significant fear or anxiety about being in social situations. There is distressing anxiety about being scrutinized, judged, or criticized by others. Examples of social situations that might provoke anxiety include having a conversation, meeting unfamiliar people, being observed eating or drinking, and performing in front of others. Often there is a fear of being humiliated, embarrassed, or rejected by others. These social situations are often avoided by people with social anxiety or experienced with significant discomfort. Many times drugs and alcohol are used in excess to minimize the anxious feelings.  

DSM-5 Criteria

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). 

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if Performance only: If the fear is restricted to speaking or performing in public.

Treatment Options for Social Anxiety Disorder

Therapy:

Cognitive Behavioral Therapy

Exposure Therapy

Interpersonal Psychotherapy

Psychodynamic Psychotherapy

Medications:

Selective Serotonin Reuptake Inhibitors

Serotonin Norepinephrine Reuptake Inhibitors

Propranolol (Inderal)

Benzodiazepines

Panic Attacks

What are Panic Attacks?

Panic attacks can occur alone or as part of another anxiety disorder or psychiatric disorder such as depression, posttraumatic stress disorder, and substance use disorders. Panic attacks can also be caused or worsened by some medical conditions such as heart disease, thyroid disease, lung disease, inner ear problems, or stomach/intestinal issues. Panic attacks are defined as an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During a panic attack, an individual may experience any combination of the following symptoms:

Palpitations, pounding heart, or accelerated heart rate.

Sweating.

Trembling or shaking.

Sensations of shortness of breath or smothering.

Feelings of choking.

Chest pain or discomfort.

Nausea or abdominal distress.

Feeling dizzy, unsteady, light-headed, or faint.

Chills or heat sensations.

Paresthesias (numbness or tingling sensations).

Derealization (feelings of unreality) or depersonalization (being detached from oneself).

Fear of losing control or “going crazy.”

Fear of dying

*It is important to note that panic attacks alone are not a mental disorder.

What is Panic Disorder?

When an individual experiences repeated and unexpected panic attacks we call it Panic Disorder. The individual begins to worry about having future panic attacks (in other words, worries about worrying). The fear of having another panic attack causes isolating and avoiding behaviors. This can lead to problems in their lives.

How is Panic Disorder Treated?

Like most anxiety disorder, the best treatment is a combination of therapy and medication. Some people don’t require medication and therapy is enough. However, therapy and medication together provides more relief than either alone. The type of therapy and medication will depend on the individual and the experience of the mental health professional. 

Therapy:

Cognitive Behavioral Therapy

Exposure Therapy

Interpersonal Psychotherapy

Psychodynamic Psychotherapy

Medications:

Selective Serotonin Reuptake Inhibitors (used to prevent future panic attacks)

Serotonin Norepinephrine Reuptake Inhibitors (used to prevent future panic attacks)

Propranolol (Inderal)

Benzodiazepines (used to abort the panic attack)

What is Agoraphobia?

Agoraphobia is a marked fear or anxiety about any of the following situations:

  • Using public transportation (e.g., automobiles, buses, trains, ships, planes).
  • Being in open spaces (e.g., parking lots, marketplaces, bridges).
  • Being in enclosed places (e.g., shops, theaters, cinemas).
  • Standing in line or being in a crowd.
  • Being outside of the home alone.

Individuals with agoraphobia avoid these situations because they feel that escape might be difficult and/or help might not be available.  Typically, individuals experience fear or anxiety that is out of proportion to the actual danger posed by the situation.

Summary of Anxiety Treatment

DisorderFirst-Line Treatment
Generalized Anxiety DisorderSSRI +/- CBT*
Panic DisorderSSRI +/- CBT*
Social Anxiety Disorder (Social Phobia)SSRI +/- CBT
Obsessive Compulsive DisorderSSRI +/- ERP +/- ACT
Acute Stress Disorder/PTSDSSRI +/- CBT +/- PET
*Benzodiazepines may be used in the short term
CBT, Cognitive Behavioral Therapy; SSRI, Selective Serotonin Reuptake Inhibitor; ERP, Exposure Response Prevention; ACT, Acceptance Commitment Therapy; PET, Prolonged Exposure Therapy

VIDEO: Anxiety and Fear in the Brain

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