Fear and stress reactions are essential for human survival. They enable people to pursue important goals and to respond appropriately to danger. In a healthy individual, the stress response (fight or flight) is provoked by a genuine threat or challenge and is used as a spur for appropriate action.
An anxiety disorder, however, involves an excessive or inappropriate state of arousal characterized by feelings of apprehension, uncertainty, or fear of a potential threat. The word is derived from the Latin, angere, which means to choke or strangle. The anxiety response is often not triggered by an actual threat or danger. Nevertheless it can still paralyze someone into inaction or withdrawal. An anxiety disorder persists, while an appropriate response to a threat resolves, once the threat is removed.
Anxiety disorders are classified according to specific symptoms and behaviors. Types of anxiety disorders include:
- Generalized Anxiety Disorder (GAD)
- Panic Disorder and Panic Attacks
- Specific Phobias
- Social Anxiety Disorder (Social Phobia)
- Separation Anxiety Disorder and Selective Mutism (which typically although not exclusively occur in children)
The American Psychiatric Association no longer classifies obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) as anxiety disorders. However, because these mental health conditions share some characteristics of anxiety disorders, they are included in this report.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is the most common anxiety disorder. It affects about 5% of Americans over the course of their lifetimes. It is characterized by:
- A more-or-less constant state of worry and anxiety, which is out of proportion to the level of actual stress or threat in one's life.
- The anxiety occurs on most days during a period of more than 6 months despite the lack of an obvious or specific stressor. (It worsens with stress, however.)
- Patients with GAD may experience physical symptoms (such as gastrointestinal complaints) in addition to, or even in place of, mental worries.
- People with GAD tend to be unsure of themselves, overly perfectionist, and conforming.
A diagnosis of GAD is made if three or more of the following symptoms are present (only one for children) on most days for 6 months:
- Being on edge or very restless
- Feeling tired
- Having difficulty concentrating
- Being irritable
- Having muscle tension
- Experiencing disturbed sleep (difficulty falling or staying asleep, having restless or unsatisfying sleep)
People with GAD often have accompanying symptoms such as sweating, nausea, diarrhea, and an extreme startle response. They may also have other health conditions associated with stress such as irritable bowel syndrome and headaches. It is very common for GAD to occur along with another type of anxiety disorder or depression disorder.
Panic Disorder and Panic Attacks
Panic disorder is characterized by periodic attacks of anxiety or terror (panic attacks).
Panic attacks can occur in nearly every anxiety disorder, not just panic disorder. A person may be in a calm state prior to the attack, or they may be feeling anxious. Panic attacks can be either:
Unexpected. Resulting "out of the blue" from no obvious cue or trigger.
Expected. Resulting from a situation that typically provokes such attacks.
Panic attacks usually last a few minutes and are accompanied by an intense surge of fear and physical discomfort. A panic attack may also be accompanied by the following symptoms:
- Rapid heartbeat or pounding heart
- Shortness of breath
- Feeling of being choked or smothered
- Dizziness or lightheadedness
- Feelings of unreality
- Either hot flashes or chills
- Chest pain
- Fear of losing control or "going crazy"
- Fear of dying
Frequency of attacks can vary widely. Some people have frequent attacks (for example, every week) that occur for months; others may have clusters of daily attacks followed by weeks or months of remission.
Agoraphobia is described as fear of being in public places or open areas. The term comes from the Greek word agora, meaning outdoor marketplace.
In its severest form, agoraphobia is characterized by a paralyzing terror of being in places or situations from which the patient feels there is neither escape nor accessible help in case of an attack. Consequently, people with agoraphobia confine themselves to places in which they feel safe, usually at home.
The patient with agoraphobia often makes complicated plans in order to avoid confronting feared situations and places. About 30 to 50% of people with agoraphobia experience panic disorder and panic attacks. However, the American Psychiatric Association now classifies agoraphobia as a separate and distinct anxiety disorder.
Specific Phobias and Social Anxiety Disorder (Social Phobia)
Phobias, manifested by overwhelming and irrational fears, are a common type of anxiety disorder.
Specific Phobias. Specific phobias (formerly simple phobias) are an irrational fear of specific objects or situations that is out of proportion to the actual danger posed. Specific phobias are very common.
The most common specific phobias are fear of animals (usually spiders, snakes, or mice), flying (pterygophobia), heights (acrophobia), water, injections, public transportation, confined spaces (claustrophobia), dentists (odontiatophobia), storms, tunnels, and bridges. Sometimes specific phobias develop because of a traumatic event. Other times, there does not seem to be any explanation for why they arise. Specific phobias can begin during childhood, or in adulthood.
When confronting the object or situation, the phobic person experiences panicky feelings, sweating, avoidance behavior, difficulty breathing, and a rapid heartbeat. Children may express their fear through crying, tantrums, freezing, and clinging. Most phobic adults are aware their fears are unreasonable and irrational, but often overestimate the danger involved in the feared situation. In fact, even thinking about the phobic object or situation can trigger intense anxiety.
Social Anxiety Disorder. Social anxiety disorder, also known as social phobia, is an intense fear of social situations and being publicly scrutinized and humiliated by others. It is manifested by extreme shyness and discomfort in social settings. This phobia often leads people to avoid social situations and social interactions, such as eating in public, giving a speech, or meeting unfamiliar people.
Social anxiety disorder is much more than shyness. People with social anxiety disorder fear that they will act in ways that will cause people to judge them negatively. They worry excessively that their actions will cause them to be embarrassed or, that they may offend others. They fear that people will think they are anxious, weak, crazy, stupid, boring, dirty, or unlikeable.
Due to their intense fears and anxieties of social situations, people with this disorder will often seek employment that requires little person-to-person contact. Accompanying mental health disorders are common. They include substance abuse, depression, body dysmorphic disorder, and bipolar disorder.
Separation Anxiety Disorder and Selective Mutism
Separation Anxiety. Separation anxiety disorder almost always occurs in children, although it can also occur in adults. It is suspected in children who are excessively anxious about separation from important family members or from home. For a diagnosis of separation anxiety disorder, the child should also exhibit at least three of the following symptoms for at least 4 weeks:
- Extreme distress from either anticipating or actually being away from home or being separated from a parent or other loved one
- Extreme worry about losing or about possible harm befalling a loved one
- Intense worry about getting lost, being kidnapped, or otherwise separated
- Frequent refusal to go to school or to sleep away from home
- Physical symptoms such as headache, stomach ache, or even vomiting, when faced with separation
Separation anxiety often disappears as the child grows older, but if not addressed, it may lead to panic disorder, agoraphobia, or other anxiety disorders.
Selective Mutism. Children with selective mutism are capable of speech but do not talk in social situations due to their intense social anxiety. These children will usually speak normally when inside the home and in the presence of immediate family members. Selective mutism is a relatively rare childhood anxiety disorder.
Obsessive-compulsive disorder (OCD) is a condition marked by unwanted intrusive and repeated thoughts (obsessions) and behaviors (compulsions):
Obsessions are recurrent or persistent mental images, thoughts, or ideas. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre and frightening fantasies of behaving violently toward a loved one.
Compulsive behaviors are repetitive, rigid, and self-directed routines that are intended to prevent the manifestation of an associated obsession. Such compulsive acts might include repetitive checking for locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or to spend inordinate amounts of time cleaning their surroundings in order to subdue the fear of contagion.
A feature of this disorder is an inflated sense of responsibility, in which the patient's thoughts center on possible dangers and an urgent need to do something about them. Although people with OCD recognize that the obsessive thoughts and ritualized behavior patterns are senseless and excessive, they cannot stop them. OCD is technically not an anxiety disorder, but it often accompanies depression, eating disorders, or other anxiety disorders. Some patients find that their symptoms subside over time, while others experience a worsening of symptoms.
Associated Obsessive Disorders. The American Psychiatric Association classifies OCD as part of a group of related disorders that include:
- Body dysmorphic disorder (BDD). In BDD, people are obsessed with the belief that they are ugly, or part of their body is abnormally shaped.
- Hoarding disorder. People with hoarding disorder excessively accumulate possessions and have difficulty discarding them, regardless of their actual value.
- Trichotillomania. People with trichotillomania continually pull their hair, leaving bald patches.
- Excoriation. People with excoriation obsessively pick at their skin.
Obsessive-Compulsive Personality. OCD should not be confused with obsessive-compulsive personality disorder, which defines certain character traits (being a perfectionist, excessively conscientious, morally rigid, or preoccupied with rules and order). These traits do not necessarily occur in people with obsessive-compulsive disorder.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a severe, persistent emotional reaction to a traumatic event that severely impairs one's life. PTSD used to be classified as an anxiety disorder. The American Psychiatric Association now classifies PTSD under a category called Trauma and Stressor-Related Disorders.
PTSD is triggered by experiencing or witnessing violent, life-threatening, or traumatic events. It can also occur from learning that traumatic events occurred to a close family member or friend. Such events include, but are not limited to, sexual assaults, accidents, military combat, natural disasters (such as earthquakes), or unexpected deaths of loved ones.
Symptoms of PTSD may begin up to 3 months after the trauma or can develop months or years later. Symptoms can include:
Re-experiencing. Patients persistently re-experience the trauma in at least one of the following ways: in recurrent images, thoughts, flashbacks, dreams, or feelings of distress at situations that remind them of the traumatic event. Children may engage in play, in which traumatic events are enacted repeatedly.
Avoidance. Patients may avoid reminders of the event, such as thoughts, people, places, objects, or any other factors that trigger recollection.
Negative and Distorted Thoughts. Patients tend to have an emotional numbness, a sense of being in a daze or of losing contact with their own identity or even external reality. They may be unable to remember important aspects of the event. They may also have persistent negative feelings about themselves and the world, and feel estranged from those around them.
Increased Arousal. This includes symptoms of anxiety or heightened awareness of danger (sleeplessness, irritability, being easily startled, or becoming overly vigilant to unknown dangers).