Anxiety Disorders

What is Anxiety?

Anxiety is a normal response to perceived threat. For this reason, anxiety serves an important evolutionary purpose. In the face of danger, anxiety initiates a cascade of events that ultimately increase survival. When we see a poisonous snake, it behooves us 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 consistently 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 (e.g., starting a new job, moving, giving a presentation, disturbing thoughts, etc.). Other times, “Anxiety” is used to describe more persistent feelings of worry, nervousness, or fear that occurs without an identifiable trigger. 

Anxiety comes in many different flavors. Here, we categorize anxiety symptoms into four general categories:

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

Below we provide the diagnostic criteria (from the Diagnostic and Statistical Manual) and other relevant information about common anxiety disorders. Please note that Obsessive Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) are considered anxiety related disorders and are reviewed elsewhere. 

ANXIETY DISORDERS

Generalized Anxiety Disorder

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

 

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)

Specific Phobia

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

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 in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). Panic attacks are defined as an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time an individual experiences 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?

Panic Disorder is diagnosed when an individual experiences recurrent, unexpected panic attacks and begins to persistently worry about having future panic attacks. The fear of having another panic attack causes individuals to isolate and avoid certain situations or events which leads to dysfunction in their lives.

 

How is Panic Disorder Treated?

 

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 the following situations for at least about 6 months:

  • 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 of thoughts that escape might be difficult or help might not be available.  Typically, individuals experience fear or anxiety that is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

The Neurobiology of Anxiety and Fear