Anxiety disorders are mental disorders characterized by excessive anxiety and fear and related behavioral disturbances. Anxiety is a commonplace experience, and occasional anxiety or fear is not indicative of an anxiety disorder, although anxiety disorders may be associated with or caused by another medical condition, medication side effects, or other psychiatric disorders.
Anxiety disorders are the most common mental disorders, affecting more than 25 million Americans of all ages and social backgrounds. However, different anxiety disorders vary widely in their prevalence in the general population, age of onset, family patterns, and gender distribution. While anxiety disorders caused by medical conditions or substance abuse are less age- and gender-specific, most anxiety disorders are approximately twice as common in females as in males. Panic disorder and generalized anxiety disorder (GAD) are more likely to develop in young adults, whereas phobias often begin in childhood. Among U.S. adults in any given year, it is estimated that:
- 7%–9% suffer from specific phobia
- 7% have social anxiety disorder
- 2%–3%– have panic disorder
- 2% have agoraphobia (fear of specific places or situations)
- 2% have GAD
- 1%–2% have separation anxiety disorder
Anxiety disorders can interfere with work, schooling, and family life. They also contribute to the high rates of alcohol and substance abuse among Americans. Physical symptoms of anxiety disorders are frequent causes of primary-care physician and emergency department visits.
Prior to 1980, psychiatrists classified patients according to the theory that anxiety resulted from unconscious conflicts. Subsequent revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the handbook used by medical professionals to diagnose mental disorders—introduced and refined the classifications based on discoveries surrounding the biochemical and post-traumatic origins of some types of anxiety and on observed and reported symptoms.
Many researchers believe that anxiety is synonymous with fear, occurring in varying degrees and in situations in which people feel threatened by some danger, real or imagined. Others describe anxiety as an unpleasant emotion caused by unidentifiable or nonexistent dangers, whereas fear is caused by real, identifiable dangers, making anxiety more difficult to identify and alleviate. Rather than attempting to formulate a strict definition of anxiety, many psychologists simply distinguish between normal, objective anxiety and a neurotic disorder. Normal anxiety occurs when people react appropriately to an anxiety-inducing situation, such as stage fright or feeling anxious on the first day at a new job. There is little, if any, real danger posed by such situations, yet they can induce intense anxiety that may affect or derail a person’s performance. Nevertheless, despite such anxieties, most people carry on and adapt. In contrast, anxiety disorders are disproportionately intense, with anxious feelings that interfere with a person’s ability to carry out normal or desired activities.
Types of anxiety disorders
The fifth edition of the DSM (DSM-5) defines 11 categories of anxiety disorders.
- Panic disorder is characterized by recurrent, unexpected panic attacks—abrupt surges of intense fear or discomfort, which usually include physical symptoms.
- Specific phobia is intense fear or anxiety concerning one or more specific objects or situations. Individuals are compelled to avoid those objects or situations if possible. Some phobias concern activities or objects that involve some degree of risk, such as flying or heights, but many are focused on animals or objects.
- Social anxiety disorder or social phobia is fear or anxiety of one or more social situations in which an individual may be scrutinized or judged by others. Inducing situations can range from having a simple conversation to public speaking.
- GAD is excessive anxiety and worry with regard to multiple events or activities, such as may occur at school or work, and affecting people on the majority of days over at least six months.
- Separation anxiety disorder is developmentally inappropriate, excessive fear or anxiety over separation from home or those to whom the individual is attached.
- Selective mutism is the consistent failure to speak in specific social situations, such as at school. This is a rare disorder that most often affects young children.
- Agoraphobia is intense fear or anxiety caused by anticipated or real exposure to common situations, such as open or enclosed spaces, crowds, public transportation, or being alone outside of the home.
- Substance/medication-induced anxiety disorder is anxiety or panic attacks caused by a substance such as an abused or prescribed drug or a toxin.
- Anxiety disorder due to another medical condition is anxiety or panic attacks caused by another physiological condition.
- Other specified anxiety disorder is a condition causing distress or impairment with symptoms characteristic of anxiety disorders but not meeting the full criteria for a specific disorder. Examples would be panic attacks with limited symptoms or generalized anxiety occurring on less than half of days.
- Unspecified anxiety disorder is a condition with symptoms of anxiety causing distress or impairment but without meeting the full criteria for any classified anxiety disorder. This includes situations where there is insufficient information, such as emergency department diagnoses.
Earlier revisions of the DSM included obsessive-compulsive disorder (OCD), acute stress disorder, and posttraumatic stress disorder (PTSD) as anxiety disorders. However, the DSM-5 classifies OCD and PTSD as distinct mental disorders. It also classifies agoraphobia as a specific type of anxiety disorder, rather than a possible symptom of panic disorder as in previous editions.
Excessiveness and persistence beyond developmentally appropriate ages distinguish anxiety disorders from developmentally normal, often stress-induced, fear or anxiety. The determination of excessiveness may be made by a clinician. Persistence is typically defined as lasting at least six months. For example, transient separation anxiety is common in children, but its persistence into childhood, adolescence, or adulthood is indicative of separation anxiety disorder.
Causes and symptoms
Each type of anxiety disorder has a variety of causes and symptoms. Causes can include various individual and general social factors that may produce physical, cognitive, emotional, and/or behavioral symptoms. Patients’ ethnic or cultural backgrounds, as well as environmental factors, can influence vulnerability to certain anxiety disorders. Genetic factors resulting in biochemical abnormalities or neurological differences may play a role in the development of anxiety disorders.
The DSM-5 delineates specific diagnostic criteria for each anxiety disorder. Panic attacks, which are a particular type of fear response, are common symptoms of various anxiety disorders. However, panic attacks also occur with other mental disorders.
Diagnoses of anxiety disorders are complicated by the variety of causes of anxiety and the range of disorders that may include anxiety as a symptom. They are best diagnosed by an experienced mental-health professional, especially a psychiatrist. Diagnosis includes a complete evaluation of the patient’ psychological, behavioral, and physical symptoms and their cause(s). Conditions other than an anxiety disorder may be secondary or primary factors in the diagnosis. Furthermore, many patients with anxiety disorders have features or symptoms of more than one disorder, and anxiety or panic attacks can be caused by another mental disorder, such as schizophrenia or major depressive disorder.
The patient will be evaluated for other medical conditions known to cause panic attacks or anxiety, as well as for substance abuse or medications that can cause anxiety. Typically, the patient will be asked about caffeine consumption and other dietary habits. The patient’s work and family situations will be discussed.
There are no laboratory tests for diagnosing anxiety disorder. However, laboratory tests may be performed to identify other medical conditions associated with anxiety; for example, tests for blood sugar and thyroid function. There are several short-answer interviews and symptom inventories that can be used to evaluate the type and intensity of a patient’s anxiety and fear. These measures include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).
Anxiety disorders are usually treated with psychotherapy, medication, or both. The specific treatment process is based on the specific type of anxiety disorder and symptoms, as well as personal preferences, other medications being used, and other treatments being administered. For relatively mild anxiety disorders, psychotherapy alone may be sufficient. A combination of medication and psychotherapy is generally preferred for more severe cases, and most patients respond better to a combination of treatment methods than to either medication or psychotherapy alone.
Medications are prescribed by medical professionals, usually psychiatrists, who may also provide psychotherapy services, sometimes as part of a team that may include psychologists, therapists, counselors, and/or social workers. Medications for anxiety disorders include various types of antidepressants, antianxiety drugs, and beta-blockers. It is difficult to predict which drug or drug combination will be most helpful for a specific patient. A medication may be given a six–eight-week trial to assess its effectiveness. Often, multiple trials are required to identify an effective drug without undesirable side effects. In many cases, less-effective medicines nevertheless help control the anxiety while initiating psychotherapy.
Antidepressants are very effective for anxiety disorders. Under normal circumstances, antidepressants take from four to six weeks to become fully effective. Widely used antidepressants for anxiety disorders include:
- Selective serotonin reuptake inhibitors (SSRIs) increase the concentration of the neurotransmitter serotonin in the brain. SSRIs are commonly started at low doses, with dosage increases at regular intervals until an appropriate plateau has been reached. SSRIs have fewer side effects than older antidepressants used for anxiety disorders. Side effects include nausea, nervousness, and sexual dysfunction, which usually fade with time. Common SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
- Tricyclics are older antidepressants that are as effective as SSRIs for anxiety disorders. Dosages usually start small and are gradually increased as needed. Side effects include dizziness, dry mouth, drowsiness, and weight gain. Commonly used tricyclics include imipramine (Tofranil) and clomipramine (Anafranil).
- Monoamine oxidase inhibitors (MAOIs) are the oldest type of antidepressants used for anxiety disorders. MAOIs have a number of side effects and interact with a variety of foods and beverages that contain tyramine and with numerous medications, including certain pain relievers and cold and allergy remedies. MAOIs can also interact with SSRIs and cause serious symptoms, including seizures and blood pressure and heart irregularities. Patients should well-informed as to potential adverse interactions. The most frequently used MAOIs are isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate).
Benzodiazepines are effective for countering anxiety; however, they can be habit-forming and may require increasingly higher dosages to remain effective. Therefore, they are generally used only for short periods. Doses must be gradually reduced before completely stopping the drugs. Benzodiazepines can cause drowsiness in some patients. Clonazepam (Klonopin), lorazepam (Ativan), and alprazolam (Xanax) are benzodiazepines that are often prescribed for specific anxiety disorders. Buspirone (Buspar), an azapirone drug, is a newer type of antianxiety medication used to treat GAD.
Beta-blockers, which are frequently used to treat cardiovascular conditions, are sometimes used for anxiety disorders. In particular, they may be prescribed for social anxiety disorder; for example, to reduce fear of speaking in front of an audience. Propranolol (Inderal) is a commonly used beta-blocker.
Psychotherapy administered by a well-trained and experienced mental-health professional can be effective for treating anxiety disorders. Effective psychotherapy requires that patients be actively engaged in their treatment.
Psychiatrists, psychologists, social workers, therapists, and counselors use cognitive-behavioral therapy (CBT) to help patients identify their specific problems, their causes, and how to react when symptoms occur. Each patient is considered a unique case and must be treated on an individualized basis. For example, patients with social anxiety disorder may come to recognize that their physical symptoms result from their fear of public speaking, and they learn proactive means of minimizing their fear in those situations. People with other types of anxiety disorders are helped to confront their fears and to desensitize themselves to anxiety-provoking situations.
Treatment in children and adolescents
A combination of CBT and medication has been shown to be the most successful form of treatment in children aged 7–17. However, antidepressants must be used with caution in children and adolescents. Some drugs are not approved for children younger than 18, and children and adults up to age 24 are at increased risk of developing suicidal thoughts and behavior with some drugs. SSRIs are the most commonly prescribed antianxiety medications in children. Parents should discuss all treatment options with their child’s physician and watch for signs of any harmful behavior or worsening depression.
There are various alternative treatments for anxiety disorders. Meditation and mindfulness training appear to be beneficial for patients with phobias and panic disorder. Hydrotherapy is useful for some anxious patients, because it promotes general relaxation of the nervous system. Yoga, aikido, tai chi, and dance therapy help patients with physical and emotional causes and symptoms of anxiety.
Homeopathy and traditional Chinese medicine approach anxiety as a symptom of a systemic disorder. Homeopathic practitioners select remedies based on other associated symptoms and the patient’s general constitution. Chinese medicine regards anxiety as a blockage of qi, or vital force, inside the body that is most likely to affect the lung and large intestine meridian flow. Chinese medicine practitioners use acupuncture points and/or herbal therapy to move the qi and rebalance the entire system in relation to the lungs and large intestine.
Although anxiety disorders can be difficult to diagnose, it is important that patients with severe anxiety symptoms obtain help. Anxiety disorders often do not resolve on their own and can progress to more frequent panic attacks, additional phobias, and episodes of depression. An untreated anxiety disorder may eventually lead to major depressive disorder or interfere with the individual’s relationships, education, or ability to hold a job. In addition, many people with anxiety disorders develop addictions to drugs or alcohol as they attempt to “self-medicate.” Moreover, since children learn ways of coping with anxiety from their parents, adults who get treatment for anxiety disorders are in a better position to help their families cope with factors that lead to anxiety.
The prognosis for recovery depends on the specific disorder, the severity of the patient’s symptoms, the specific causes of the anxiety disorder, and the patient’s degree of control over these causes. With appropriate treatment by medical professionals, most people with anxiety disorders can achieve normal daily life.
Anxiety is an unavoidable feature of human existence. However, humans have some power over their reactions to anxiety-provoking events and situations. Cognitive therapy and meditation or mindfulness training appear to be beneficial for helping people lower their anxiety levels over the long term.