Anxiety Disorders
Introduction
Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.1 These disorders fill people’s lives with overwhelming anxiety and fear. Unlike the relatively mild, brief anxiety caused by a stressful event such as a business presentation or a first date, anxiety disorders are chronic, relentless, and can grow progressively worse if not treated.
Effective treatments for anxiety disorders are available, and research is yielding new, improved therapies that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment.
The anxiety disorders discussed in this article are:
- panic disorder
- obsessive-compulsive disorder
- post-traumatic stress disorder
- social phobia (or social anxiety disorder)
- specific phobias
- and generalized anxiety disorder
Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread.
Panic Disorder
“It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying.
“For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I’m losing control in a very extreme way. My heart pounds really hard, I feel like I can’t get my breath, and there’s an overwhelming feeling that things are crashing in on me.
“In between attacks there is this dread and anxiety that it’s going to happen again. I’m afraid to go back to places where I’ve had an attack. Unless I get help, there soon won’t be anyplace where I can go and feel safe from panic.”
People with panic disorder have feelings of terror that strike suddenly and repeatedly with no warning. They can’t predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike.
If you are having a panic attack, most likely your heart will pound and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have nausea, chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. You may genuinely believe you’re having a heart attack or losing your mind, or on the verge of death.
Panic attacks can occur at any time, even during sleep. An attack generally peaks within 10 minutes, but some symptoms may last much longer.
Panic disorder affects about 2.4 million adult Americans1 and is twice as common in women as in men.2 It most often begins during late adolescence or early adulthood.2 Risk of developing panic disorder appears to be inherited.3 Not everyone who experiences panic attacks will develop panic disorder-for example, many people have one attack but never have another. For those who do have panic disorder, though, it’s important to seek treatment. Untreated, the disorder can become very disabling.
Many people with panic disorder visit the hospital emergency room repeatedly or see a number of doctors before they obtain a correct diagnosis. Some people with panic disorder may go for years without learning that they have a real, treatable illness.
Panic disorder is often accompanied by other serious conditions such as depression, drug abuse, or alcoholism4,5 and may lead to a pattern of avoidance of places or situations where panic attacks have occurred. For example, if a panic attack strikes while you’re riding in an elevator, you may develop a fear of elevators. If you start avoiding them, that could affect your choice of a job or apartment and greatly restrict other parts of your life.
Some people’s lives become so restricted that they avoid normal, everyday activities such as grocery shopping or driving. In some cases they become housebound. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person.
Basically, these people avoid any situation in which they would feel helpless if a panic attack were to occur. When people’s lives become so restricted, as happens in about one-third of people with panic disorder,2 the condition is called agoraphobia. Early treatment of panic disorder can often prevent agoraphobia.
Panic disorder is one of the most treatable of the anxiety disorders, responding in most cases to medications or carefully targeted psychotherapy.
You may genuinely believe you’re having a heart attack, losing your mind, or are on the verge of death. Attacks can occur at any time, even during sleep.
Depression
Depression often accompanies anxiety disorders4 and, when it does, it needs to be treated as well. Symptoms of depression include feelings of sadness, hopelessness, changes in appetite or sleep, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of both.
Obsessive-Compulsive Disorder
“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a “bad” number.
“Getting dressed in the morning was tough because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.
“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”
Obsessive-compulsive disorder, or OCD, involves anxious thoughts or rituals you feel you can’t control. If you have OCD, you may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals.
You may be obsessed with germs or dirt, so you wash your hands over and over. You may be filled with doubt and feel the need to check things repeatedly. You may have frequent thoughts of violence, and fear that you will harm people close to you. You may spend long periods touching things or counting; you may be pre-occupied by order or symmetry; you may have persistent thoughts of performing sexual acts that are repugnant to you; or you may be troubled by thoughts that are against your religious beliefs.
The disturbing thoughts or images are called obsessions, and the rituals that are performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the anxiety that grows when you don’t perform them.
A lot of healthy people can identify with some of the symptoms of OCD, such as checking the stove several times before leaving the house. But for people with OCD, such activities consume at least an hour a day, are very distressing, and interfere with daily life.
Most adults with this condition recognize that what they’re doing is senseless, but they can’t stop it. Some people, though, particularly children with OCD, may not realize that their behavior is out of the ordinary.
OCD afflicts about 3.3 million adult Americans.1 It strikes men and women in approximately equal numbers and usually first appears in childhood, adolescence, or early adulthood.2 One-third of adults with OCD report having experienced their first symptoms as children. The course of the disease is variable-symptoms may come and go, they may ease over time, or they can grow progressively worse. Research evidence suggests that OCD might run in families.3
Depression or other anxiety disorders may accompany OCD,2,4 and some people with OCD also have eating disorders.6 In addition, people with OCD may avoid situations in which they might have to confront their obsessions, or they may try unsuccessfully to use alcohol or drugs to calm themselves.4,5 If OCD grows severe enough, it can keep someone from holding down a job or from carrying out normal responsibilities at home.
OCD generally responds well to treatment with medications or carefully targeted psychotherapy.
The disturbing thoughts or images are called obsessions, and the rituals performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the anxiety that grows when you don’t perform them.
Post-Traumatic Stress Disorder
“I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.
“Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.
“The rape happened the week before Thanksgiving, and I can’t believe the anxiety and fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I can’t relax, can’t sleep, don’t want to be with anyone. I wonder whether I’ll ever be free of this terrible problem.”
Post-traumatic stress disorder (PTSD) is a debilitating condition that can develop following a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include violent attacks such as mugging, rape, or torture; being kidnapped or held captive; child abuse; serious accidents such as car or train wrecks; and natural disasters such as floods or earthquakes. The event that triggers PTSD may be something that threatened the person’s life or the life of someone close to him or her. Or it could be something witnessed, such as massive death and destruction after a building is bombed or a plane crashes.
Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience other sleep problems, feel detached or numb, or be easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Things that remind them of the trauma may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the traumatic event are often very difficult.
PTSD affects about 5.2 million adult Americans.1 Women are more likely than men to develop PTSD.7 It can occur at any age, including childhood,8 and there is some evidence that susceptibility to PTSD may run in families.9 The disorder is often accompanied by depression, substance abuse, or one or more other anxiety disorders.4 In severe cases, the person may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was deliberately initiated by a person-such as a rape or kidnapping.
Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, may lose touch with reality and believe that the traumatic event is happening all over again.
Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do develop PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn’t show up until years after the traumatic event.
People with PTSD can be helped by medications and carefully targeted psychotherapy.
Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. Anniversaries of the traumatic event are often very difficult.
Social Phobia (Social Anxiety Disorder)
“In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick at my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.
“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.
“I couldn’t go on dates, and for a while I couldn’t even go to class. My sophomore year of college I had to come home for a semester. I felt like such a failure.”
Social phobia, also called social anxiety disorder, involves overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school, and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.
Social phobia can be limited to only one type of situation-such as a fear of speaking in formal or informal situations, or eating, drinking, or writing in front of others-or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating-it may even keep people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.
Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking. If you suffer from social phobia, you may be painfully embarrassed by these symptoms and feel as though all eyes are focused on you. You may be afraid of being with people other than your family.
People with social phobia are aware that their feelings are irrational. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.
Social phobia affects about 5.3 million adult Americans.1 Women and men are equally likely to develop social phobia.10 The disorder usually begins in childhood or early adolescence,2 and there is some evidence that genetic factors are involved.11 Social phobia often co-occurs with other anxiety disorders or depression.2,4 Substance abuse or dependence may develop in individuals who attempt to “self-medicate” their social phobia by drinking or using drugs.4,5 Social phobia can be treated successfully with carefully targeted psychotherapy or medications.
Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. Anniversaries of the traumatic event are often very difficult.
Specific Phobias
“I’m scared to death of flying, and I never do it anymore. I used to start dreading a plane trip a month before I was due to leave. It was an awful feeling when that airplane door closed and I felt trapped. My heart would pound and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn’t get out. When I think about flying, I picture myself losing control, freaking out, climbing the walls, but of course I never did that. I’m not afraid of crashing or hitting turbulence. It’s just that feeling of being trapped. Whenever I’ve thought about changing jobs, I’ve had to think,’Would I be under pressure to fly?’ These days I only go places where I can drive or take a train. My friends always point out that I couldn’t get off a train traveling at high speeds either, so why don’t trains bother me? I just tell them it isn’t a rational fear.”
A specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.
Specific phobias affect an estimated 6.3 million adult Americans1 and are twice as common in women as in men.1011 Specific phobias usually first appear during childhood or adolescence and tend to persist into adulthood.12 The causes of specific phobias are not well understood, though there is some evidence that these phobias may run in families.
If the object of the fear is easy to avoid, people with specific phobias may not feel the need to seek treatment. Sometimes, though, they may make important career or personal decisions to avoid a phobic situation, and if this avoidance is carried to extreme lengths, it can be disabling. Specific phobias are highly treatable with carefully targeted psychotherapy.
Phobias aren’t just extreme fears; they are irrational fears. You may be able to ski the world’s tallest mountains with ease but feel panic going above the 5th floor of an office building.
Generalized Anxiety Disorder
“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.
“I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomachache, I’d think it was an ulcer.
“When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment.”
Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. It’s chronic and fills one’s day with exaggerated worry and tension, even though there is little or nothing to provoke it. Having this disorder means always anticipating disaster, often worrying excessively about health, money, family, or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day provokes anxiety.
People with GAD can’t seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. Their worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes. People with GAD may feel lightheaded or out of breath. They also may feel nauseated or have to go to the bathroom frequently.
Individuals with GAD seem unable to relax, and they may startle more easily than other people. They tend to have difficulty concentrating, too. Often, they have trouble falling or staying asleep.
Unlike people with several other anxiety disorders, people with GAD don’t characteristically avoid certain situations as a result of their disorder. When impairment associated with GAD is mild, people with the disorder may be able to function in social settings or on the job. If severe, however, GAD can be very debilitating, making it difficult to carry out even the most ordinary daily activities.
GAD affects about 4 million adult Americans1 and about twice as many women as men.2 The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age.2 It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD.13
GAD is commonly treated with medications. GAD rarely occurs alone, however; it is usually accompanied by another anxiety disorder, depression, or substance abuse.2,4 These other conditions must be treated along with GAD.
REFERENCES:
- Narrow WE, Rae DS, Regier DA. NIMH epidemiology note: prevalence of anxiety disorders. One-year prevalence best estimates calculated from ECA and NCS data. Population estimates based on U.S. Census estimated residential population age 18 to 54 on July 1, 1998. Unpublished.
- Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
- The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.
- Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.
- Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry, 1990; 147(6): 685-95.
- Wonderlich SA, Mitchell JE. Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacology Bulletin, 1997; 33(3): 381-90.
- Davidson JR. Trauma: the impact of post-traumatic stress disorder. Journal of Psychopharmacology, 2000; 14(2 Suppl 1): S5-S12.
- Margolin G, Gordis EB. The effects of family and community violence on children. Annual Review of Psychology, 2000; 51: 445-79.
- Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Canadian Journal of Psychiatry, 1999; 44(1): 34-9.
- Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 1988; 2: 227-41.
- Kendler KS, Walters EE, Truett KR, et al. A twin-family study of self-report symptoms of panic-phobia and somatization. Behavior Genetics, 1995; 25(6): 499-515.
- Boyd JH, Rae DS, Thompson JW, et al. Phobia: prevalence and risk factors. Social Psychiatry and Psychiatric Epidemiology, 1990; 25(6): 314-23.
- Kendler KS, Neale MC, Kessler RC, et al. Generalized anxiety disorder in women. A population-based twin study. Archives of General Psychiatry, 1992; 49(4): 267-72.
Article syndicated from National Institute of Mental Health
This brochure is a revision by Mary Lynn Hendrix of an earlier version written by Marilyn Dickey.
Scientific information and/or review for this revision were provided by Steven E. Hyman, M.D., Richard Nakamura, Ph.D., Matthew Rudorfer, M.D., Linda Street, Ph.D., and Elaine Baldwin, all of NIMH, and Una McCann, M.D., now of The Johns Hopkins University. Editorial assistance was provided by Clarissa Wittenberg, Margaret Strock, and Melissa Spearing of NIMH.
(1994/2004)