Anxiety Disorders

Anxiety disorders impact your thoughts, feelings, and behavior, as well as your physical health and well-being. Although many people try to self-manage their anxiety disorder, there are several effective treatments to treat both the symptoms and the cause of anxiety.

Key takeaways

• Anxiety disorders are extremely common, with around 31% of Americans suffering from one during their life^[2]

• Anxiety disorders are characterized by an intense fear reaction, which is long-lasting and may be considered disproportionate by others

• Anxiety is typically treated by a combination of medication and psychotherapy, although new treatment avenues are currently being explored

Causes and risks of anxiety

Anxiety disorders are extremely common. For example, 12.1% of people have experienced a phobia in the last 12 months, and 7.4% had social anxiety disorder in the same period.^[3]They don’t have a single cause. Instead, they result from the combination of genetic, biological, social, and environmental factors. Adverse events, such as bereavement or experiencing violence, increase the risk that you will develop an anxiety disorder.^[4]

Some of the features and symptoms of anxiety disorders, such as increased heart rate or excessive alcohol or substance use, can lead to other health problems in the future, including cardiovascular disease, gastrointestinal illness, and migraines.^[4]

The difference between stress and anxiety

Feeling fear, stress, and even anxiety is normal. Life can give us reasons to worry, and approximately 65% of Americans rate their stress levels at 4 out of 10 or above.^[5]

An anxiety disorder is different. For someone with an anxiety disorder, their emotional experience is more intense and longer-lasting. Someone with an anxiety disorder struggles to put their worries aside and may go to extreme lengths to avoid stimuli or situations that trigger their anxiety.^[3]

When someone has an anxiety disorder, their worry or stress will often appear disproportionate to others. They may be highly concerned about extremely unlikely events, and their efforts to feel safe can harm their lives. They may not always be able to express what they are worried about.

Anxiety symptoms

Symptoms of anxiety disorders can be divided into different categories.

Emotional symptoms

Emotional symptoms are the defining characteristic of an anxiety disorder. People with these disorders have intense, often disproportionate, emotional reactions to whatever triggers their anxiety.^[3]

People with an anxiety disorder will use many different words to describe how their disorder makes them feel, including

• Nervous

• Tense

• Anxious

• Afraid

• Frightened

• Terrified

In addition to feeling anxious or afraid, they may find that they are unusually irritable and frustrated.

Cognitive symptoms

Cognitive symptoms of anxiety are thoughts or beliefs that someone with anxiety might experience. Some of these might occur only during an acute anxiety attack, for example, difficulty speaking, while others may occur at any time.^[3]

Common cognitive symptoms include^[3]

• Fear of losing control or ‘going crazy’

• Fear of physical harm

• Hypervigilance

• Poor concentration

• Poor memory

• Difficulty speaking or finding words

• Dissociation or feelings of unreality

• Fear of negative social reactions

• Catastrophizing

Behavioral symptoms

Behavioral symptoms of anxiety disorders are best understood as things people with these disorders do to try to deal with their anxiety. These behaviors aren’t always voluntary or under the person’s control.

Common behavioral symptoms of anxiety disorders include^[3]

• Avoiding places, situations, or stimuli that trigger the anxiety

• Freezing

• Restlessness and pacing

• Seeking things that increase feelings of safety, including people, places, or objects

• Asking for high levels of reassurance

• Seeking escape, often including running away from frightening stimuli

• Hyperventilation and other breathing difficulties

Physiological symptoms

Anxiety produces distressing symptoms in the body, which can sometimes help to reinforce anxiety triggers.

Physiological symptoms of anxiety include^[3]

• Sweating

• Increased heart rate or palpitations

• Rapid breathing and/or a shortness of breath

• Chest pain

• Trembling or shaking

• Feeling lightheaded, dizzy, or faint

• Dry mouth

• Blushing or feeling flushed

• Nausea, upset stomach, or diarrhea

Types of anxiety disorders

Generalized anxiety disorder

Generalized anxiety disorder (GAD) involves long-lasting anxiety and excessive worry focused on many areas of a person’s life.^[3]Someone with GAD might think of themselves as a generally anxious person and find themselves worrying about work, relationships, money, health, and the future. Worries can be big, such as whether they might lose their job, or small, for example, whether a cashier thought they were rude.

GAD is more common in women and people who are unmarried, have health issues, or have a low level of education. It is also more common in people whose lives contain more stressors.^[6]

Panic disorder

Panic attacks are sudden waves of intense fear or anxiety with strong physiological symptoms, such as a pounding heart and shortness of breath. Panic disorder occurs when someone experiences repeated unexpected panic attacks that leave them worrying about the possibility of having more.^[7]

Someone with panic disorder will often experience their panic attacks as primarily physical. Because there is no obvious trigger for their fear, it feels as though the physical symptoms came first and lead to fear about their health.

Social anxiety disorder

Social anxiety disorder (SAD) is characterized by an intense fear associated with social situations, especially the fear of being viewed negatively by others.^[8]Many people with SAD feel ashamed of their anxiety. As a result, they can struggle to seek medical help or support.^[9]

Separation anxiety disorder

Separation anxiety disorder is an anxiety disorder typically experienced in childhood, and is characterized by unusually severe distress when a child is separated from their attachment figures or home environment. Separation anxiety is a normal developmental stage, typically appearing at around 6 months and diminishing after about 3 years of age. Someone with separation anxiety disorder will experience undue distress at being separated from people who are important to them, for example, parents, children, or spouses.^[10]

Someone with separation anxiety disorder may worry that either they or the person they are separated from will come to harm, potentially leading to extended, or even permanent, separation.

Specific phobias

A phobia is an excessive, irrational fear of a stimulus. This could be an object, situation, or activity. Someone with a specific phobia will typically attempt to avoid all contact with the stimulus that scares them and may experience panic attacks when they are unable to avoid it.^[11]

Agorophobia

Agoraphobia is slightly different from a specific phobia. Someone with agoraphobia experiences intense fear from situations where escape might be difficult or where help may be unavailable. These situations include open spaces, enclosed spaces, and crowds.^[12]

Selective mutism

Selective mutism occurs when someone (usually a child) can speak normally in some situations, for example at home, but does not speak in others, for example at school.^[13]

Diagnosing anxiety disorder

Diagnosis of an anxiety disorder may be carried out by your normal healthcare provider, but in many cases, they will refer you to a mental health specialist, such as a psychiatrist or psychologist.

To diagnose you with an anxiety disorder, the healthcare provider needs to be sure that you are showing positive signs of the specific anxiety disorder and be confident that those symptoms are not due to any other cause, such as any other medical conditions you may have or any medications you are taking.^[14]

One of the difficulties for medical practitioners in diagnosing anxiety disorders is that they often co-occur with other physical or mental health issues, including depression, substance use disorder, and chronic health conditions. They may ask you about things that seem unrelated to your core difficulties as a way to distinguish between different problems you may be facing.

Each anxiety disorder has specific diagnostic criteria.

Generalized anxiety disorder

For a diagnosis of GAD, you must have experienced excessive worry for at least 6 months and felt unable to control that worry. During that time, you must also have experienced at least three of^[6]

• Restlessness, feeling keyed up, or on edge

• Being easily fatigued

• Difficulty in concentrating or mind going blank, irritability

• Muscle tension

• Sleep disturbance

• Irritability

This anxiety must be causing you problems in your everyday life, and it must not be due to a physical cause.

As part of the diagnostic process, your medical practitioner might order some additional tests to rule out physical causes for your symptoms. These include

• Thyroid tests

• Blood glucose tests

• Echocardiogram

Your medical practitioner might also ask you to complete a screening questionnaire, such as the GAD-7, to assess the severity of your symptoms.

Panic disorder

Panic disorder is diagnosed based on the presence of panic attacks without an explanation and a prolonged period of worry about those panic attacks.

A panic attack is a period of intense fear that is accompanied by at least four of the following symptoms^[7]

• 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

• Numbness or tingling sensations (paresthesias)

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

• Fear of losing control or "going crazy"

• Fear of dying

An unexpected panic attack isn’t tied to a known trigger (such as a phobia).

Panic disorder can be diagnosed if you experience repeated, unexpected panic attacks and worry for at least a month about the risk of having more.

Social anxiety disorder

For a diagnosis of SAD, you must have significant, disproportionate fear or anxiety about at least one social situation. This fear must be around how you are perceived by others, for example, causing offense or being rejected, and must have lasted for at least 6 months. It must cause you distress or make your life difficult, and it cannot be due to another medical condition.^[8]

Clinicians will often use screening tools to help them diagnose SAD, such as the Liebowitz Social Anxiety Scale (LSAS).

Separation anxiety disorder

Diagnosis for separation anxiety disorder is slightly different depending on whether you are an adult or a child. Children may be offered a screening tool, such as SCARED, which is used to understand anxiety in children.

There are fewer screening tools available for adults, and a clinical interview will be used to ensure that the medical practitioner understands the difficulties you face.

When diagnosing separation anxiety disorder, doctors are looking for evidence of excessive (and developmentally inappropriate in children) anxiety during separation.^[15]This includes at least three of the following symptoms^[10]

• Recurrent excessive distress with actual or anticipated separation from home or attachment figure(s)

• Persistent and pervasive worry about losing the attachment figure(s) or possible harm befalling them, such as illness, injury, disasters, or death

• Persistent and pervasive worry that an untoward event will be experienced by the patient and lead to prolonged or permanent separation

• Reluctance or refusal to go out, such as to school or work, because of fear of separation

• Refusal to be alone at home or in other settings

• Refusal to sleep without being near the attachment figure(s)

• Repeated nightmares about separation

• Repeated physical symptoms when separation occurs or is anticipated

These symptoms must have been present for at least 4 weeks in children (6 months in adults) and cause difficulties in everyday life.

Specific phobias

Most people with a phobia are aware of their condition. Screening tests can be offered, especially for children, but diagnosis usually occurs based on self-report. For a diagnosis of phobia, you must have the same disproportionate fear of the phobic stimulus almost every time you encounter it, and your fear must be persistent (usually at least 6 months).^[11]

Agorophobia

Clinicians looking to diagnose someone with agoraphobia check whether they experience intense fear in at least two situations from the following list^[12]

• Public transportation

• Open spaces

• Enclosed spaces

• Standing in line or being in a crowd

• Being outside the home alone

As with other anxiety disorders, this fear must be enduring (at least 6 months), cause difficulties in everyday life, and not be due to other factors, such as medications or other illnesses.

Selective mutism

Selective mutism is diagnosed through a combination of a clinical interview, where possible, and discussions with people close to the patient. In this process, the doctor is looking for evidence that the person fails to speak in certain situations where they would normally be expected to speak, but that they are able to speak in other environments. The failure to speak can’t be due to a communication disorder or any struggles with language and it must have lasted for at least a month.^[13]

Knowing when to get help

Stress and anxiety, in moderation, are a normal part of life, but that doesn’t mean that you have to suffer. If you feel anxious for more than a few weeks, or if your anxiety is getting in the way of your normal daily activities, seek help from your medical practitioner.

Treatment for anxiety

Therapy for anxiety

Talking therapy is an important part of any treatment for an anxiety disorder. Cognitive behavioral therapy (CBT) is often used to help address the thought patterns and beliefs that drive excessive anxiety.^[3]

Exposure therapy slowly introduces patients to the source of their anxiety, such as a phobic stimulus. This can be effective in cases of specific phobias and other anxiety disorders, but the presence of a trained therapist is key. Friends and family should not attempt to help someone with an anxiety disorder overcome their condition by exposing them to anxiety-inducing stimuli.

Anxiety medication

Medication can help reduce the symptoms of an anxiety disorder, and is often important in allowing patients to feel able to access talking therapy.^[3]

Antidepressants

Antidepressants are often a first-line treatment for anxiety disorders. SSRIs or SNRIs can help reduce the symptoms of anxiety, as well as treat any depression you may be experiencing.

Antidepressants offered to patients with an anxiety disorder include:

• Venlafaxine

• Duloxetine

Benzodiazepines

Benzodiazepines can be effective medications for treating anxiety, but they carry a risk of dependence and abuse, so they are typically restricted to short-term use.

Beta-blockers

Beta-blockers, such as propranolol, can reduce the physical symptoms of anxiety, such as increased heart rate. These can be prescribed for daily use or to take when needed, for example, at the start of a panic attack.

Alternative treatments for anxiety

Many alternative treatments for anxiety are available. These include herbal remedies or supplements, such as St John's Wort.^[6]

If you are considering using supplements or herbal/alternative remedies for anxiety, it’s essential to speak to your doctor first. These can contain active ingredients that can interact with any prescribed medication, potentially leading to dangerous complications.

Self-managing anxiety disorders

In addition to seeking treatment, there are steps you can take to help reduce the symptoms of an anxiety disorder and help support your recovery.

It can be tempting to use alcohol or other drugs to manage symptoms of anxiety, but these are known to make the situation worse in the medium and long term. It is best to limit alcohol and drug use where possible.

Improving your physical health can help reduce your symptoms of anxiety. Taking more exercise, eating a healthy diet, and ensuring you get enough high-quality sleep can all be beneficial to your mental, as well as physical, health. Learning relaxation techniques, meditation, and mindfulness can also be effective in reducing anxiety symptoms.^[16]

Anxiety resources

Anxiety disorders are difficult mental health conditions, and it’s important to seek help in dealing with them. SAMHSA has a collection of online resources designed to help you find mental health support. This includes advice on looking after yourself, suggestions for how to help others, details of free and low-cost programs, and helplines for emergencies.