Everyone feels anxiety from time to time. Few people get through a week without some anxious tension or a feeling that something is not going to go well. We may feel anxiety when we’re facing an important event, such as an exam or job interview, or when we perceive some threat or danger, such as waking to strange sounds in the night. However, such everyday anxiety is generally occasional, mild and brief, while a person with an anxiety disorder feels anxious more frequently, more intensely and sometimes for hours or even days.
Anxiety disorders are common. Research shows that one in three adults will have an anxiety disorder in their lifetime (Bandelow & Michaelis, 2015). Anxiety disorders are the most common mental health problem in women and are second only to substance use disorders in men. Anxiety disorders can make it hard for people to work or study, to manage daily tasks and to relate to others, and they can often cause a person to experience financial strain and personal suffering.
Anxiety disorders are treatable, and early intervention can help to ensure treatment success. People often live with anxiety disorders for years before they are diagnosed and treated. If you suspect that you have an anxiety disorder, it is important to seek professional treatment as soon as possible.
The main categories of anxiety disorders are specific phobias, panic disorder, agoraphobia, generalized anxiety disorder, social anxiety disorder, selective mutism and separation anxiety disorder (American Psychiatric Association [APA], 2013).
Each of these anxiety disorders is distinct in some ways, but they all share the following features:
- irrational and excessive fear
- apprehensive and tense feelings
- difficulty managing daily tasks and/or distress related to these tasks.
In the following examples, Susan and John1 show these common characteristics, although the precise nature of their fears differ.
Susan has had recurrent and unexpected panic attacks for the past five years:
It started on a night when I was driving home in the rain. I began to feel shaky and dizzy and had trouble focusing. At first, I thought it was something that I had eaten earlier, but then my mind started to drift, and I thought, “What if I pass out?” and “What if I’m dying?” I started to shake all over, and it was as if my entire body was wired. I quickly pulled the car over and called my daughter to come and get me. Since then, I’ve had dozens and dozens of these attacks. At first, the attacks occurred just when I was driving, but now I experience them in shopping malls, standing in line-ups and even on the bus. It seems as if I spend most of my day worrying and waiting for the next attack.
John describes a lifelong pattern of being excessively shy and fearing embarrassment in social situations:
For as long as I can remember, and as far back as when I was seven years old, I hated being the centre of attention. In class, I tried to remain as invisible as possible, praying that the teacher would not call upon me to answer a question. When it was my turn to make presentations, I wouldn’t sleep for a week, worrying that I would forget what I was supposed to say, stumble over my words and look completely stupid. It’s as if nothing’s changed: now at work I dread having to attend meetings, meet with the boss, have lunch with colleagues and, the worst, give monthly reports to the team. I’m pretty sure everyone knows how uncomfortable I am, and they all probably think I look weird and sound stupid.
To better understand the nature of anxiety disorders such as those experienced by Susan and John, we need to first explore the nature of “normal” anxiety. Later in this chapter, we’ll describe the key fears and components of each major anxiety disorder.
What is normal anxiety?
A certain amount of anxiety is normal and necessary; it can lead you to act on your concerns and can protect you from harm. In some situations, anxiety can even be essential to your survival.
- Physical: excessive physical reactions relative to the context (e.g., heart racing and feeling short of breath while among crowds at a mall) that may be mistaken for symptoms of a physical illness, such as a heart attack
- Behavioural: avoidance of feared situations (e.g., driving), avoidance of activities that elicit sensations similar to those experienced when anxious (e.g., exercise), subtle avoidances (e.g., behaviours that aim to distract the person, such as talking more during periods of anxiety) and safety behaviours (e.g., habits to minimize anxiety and feel “safer,” such as always having a cell phone on hand to call for help).
Several factors determine whether the anxiety warrants the attention of mental health professionals, including:
- the degree of distress caused by the anxiety symptoms
- the effect anxiety symptoms have on a person’s ability to work or study, socialize and manage daily tasks
- the context in which the anxiety occurs.
What are the anxiety disorders?
An anxiety disorder may make people feel anxious most of the time or for brief intense episodes, which may occur for no clear reason. People with anxiety disorders may have anxious feelings that are so uncomfortable that they avoid daily routines and activities that might cause these feelings. Some people have occasional anxiety attacks so intense that they are terrified or unable to move.
People with anxiety disorders are usually aware of the irrational and excessive nature of their fears. During treatment, many say, “I know my fears are unreasonable, but I just can’t seem to stop them.”
The major categories of anxiety disorders are classified according to the focus of the anxiety. A brief description of each is given below, based on the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).
Although each anxiety disorder can have many different symptoms, one representative example has been chosen to show the typical cognitive, physical and behavioural symptoms of each disorder.
Changes in what is classified as an Anxiety Disorder
In 2013, the DSM-5 replaced the DSM-IV. In the DSM-5, separation anxiety disorder and selective mutism are included in the anxiety disorder category, and obsessive-compulsive disorder (OCD), agoraphobia without a history of panic disorder, acute stress disorder and posttraumatic stress disorder (PTSD) are no longer classified as anxiety disorders, as they were in the DSM-IV. OCD is now found in the obsessive-compulsive and related disorders category, and PTSD and acute stress disorder are found under the trauma and stressor-related disorders category.
Although OCD, acute stress disorder and PTSD are no longer classified as anxiety disorders in the DSM-5, the information
provided in this guide on cognitive-behavioural therapy, recovery, relapse prevention and considerations for families still applies to these diagnoses.
Panic Disorder
Panic disorder involves recurrent, unexpected panic attacks (e.g., heart palpitations, sweating, trembling) followed by at least one month of:
a) persistent concern about having another panic attack or the consequences of a panic attack (e.g., having a heart attack), and/or
b) significant behaviour changes related to the attacks (e.g., avoiding exercise or places for fear of having a panic attack) (APA, 2013).
Panic attacks may be accompanied by agoraphobia (see next category of anxiety disorder).
Examples of symptoms
Cognitive
- “I’m having a heart attack.”
- “I’m suffocating.”
Physical
- accelerated heart rate
- chest pain or discomfort
- dizziness, nausea
- trembling or shaking
- shortness of breath
Behavioural
- avoidance of places where the person had anxiety symptoms in the past (e.g., a certain grocery store) or similar places (e.g., all grocery stores)
- avoidance of travel, crowds, line-ups
- avoidance of strenuous activities (e.g., exercise)
Agorophobia
Agoraphobia involves marked anxiety for at least six months in at least two of the following five situations:
- using public transportation being in open spaces
- being in enclosed places
- standing in line or being in a crowd
- being alone away from home.
People with agoraphobia avoid these situations or endure them with distress. The main concern in these situations is that it would be hard to escape or that others would not be able to help if the person had panic symptoms (APA, 2013).
Examples of symptoms
Cognitive
- “I’m going to be trapped.”
- “No one will be able to help me.”
Physical
- accelerated heart rate
- shortness of breath
Behavioural
- avoidance of public transportation, open spaces, enclosed places, being out of the house alone, standing in lines and/or being in crowds
- requiring the presence of a companion in situations or places related to the anxiety
Specific Phobia
A specific phobia involves a “marked fear or anxiety about a specific object or situation” (APA, 2013, p. 197). There are five subtypes of specific phobia:
- animal type, such as fear of mice or spiders
- natural environment type, such as fear of storms or heights, blood-injection-injury type, such as fear of seeing blood or receiving an injection
- situational type, such as fear of public transportation, elevators or enclosed spaces
- other type, such as fear of choking or vomiting.
Examples of symptoms
Cognitive
- “This plane will crash.”
- “The dog will bite me.”
Physical
- sweating
- muscle tension
- dizziness
Behavioural
- avoidance of air travel
- need to escape
Social Anxiety Disorder
Social anxiety disorder (also known as social phobia) involves a “marked fear or anxiety about social situations in which the person may be exposed to possible scrutiny by others” that lasts at least six months (APA, 2013, p. 202). Fears might be associated with most social situations related to public performance or social interactions, such as participating in small groups, meeting strangers, dating or playing sports.
Examples of symptoms
Cognitive
- “I’ll look anxious and stupid.”
- “People will think I’m weird.”
Physical
- blushing
- sweating
- dry mouth
Behavioural
- avoidance of social gatherings, parties, meetings
- avoidance of public speaking
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) involves “excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities (such as work or school performance)” (APA, 2013, p. 222). GAD is characterized by difficulty in controlling worry and at least three associated physical symptoms (e.g., muscle tension, sleep difficulties, trouble concentrating).
Examples of symptoms
Cognitive
- “Something’s going to go wrong.”
- "This worry is going to make me sick.”
- “I need to be sure nothing bad is going to happen.”
Physical
- muscle tension
- feeling keyed up or on edge
- restlessness, irritability
- sleep disturbance
Behavioural
- avoidance of news, newspapers
- restricted activities due to excessive worries about what could happen
- excessive reassurance-seeking or over-preparing
Separation Anxiety Disorder
Separation anxiety disorder involves excessive fear and/or anxiety about being separated from home or from a person or people that is not appropriate to the person’s age or development. The fear, anxiety or avoidance occurs for at least one month in children or adolescents and at least six months in adults (APA, 2013).
Examples of symptoms
Cognitive
- “Something bad will happen to person X if we are not together.”
- “Some event [e.g., getting lost or sick] will take me away from person X.”
Physical
- headache
- stomach ache
- vomiting
Behavioural
- reluctance or refusal to go out, for fear of separation
- avoidance of being alone or without person X
- refusal to sleep if person X is not nearby
Selective Mutism
Selective mutism involves consistently not speaking “in specific situations where there is an expectation for speaking (e.g., at school), despite speaking in other situations” (APA, 2013, p. 195). It occurs for at least a month (longer than a month if that time period includes the first month of school) a nd often interferes with academic achievement. It often co-exists with shyness and/or social phobia.
Examples of symptoms
Cognitive
- “I wish school was shorter.”
- “What will they think of me?”
Physical
- stomach ache
- racing heart
- shortness of breath
Behavioural
- not speaking in many social situations
- speaking only in the presence of immediate family
- refusing to go to school
- difficulty making eye contact.
This text has been taken from Anxiety Disorders: An Information Guide. Learn more about the booklet, download the PDF of the booklet or purchase a copy from the CAMH Store.