Top searched topics: Anxiety Disorders

What is anxiety?

Everyone experiences symptoms of anxiety, but they are generally occasional and short-lived, and do not cause problems. But when the cognitive, physical and behavioural symptoms of anxiety are persistent and severe, and anxiety causes distress in a person’s life to the point that it negatively affects his or her ability to work or study, socialize and manage daily tasks, it may be beyond the normal range.

The following examples of anxiety symptoms may indicate an anxiety disorder:
1. cognitive: anxious thoughts (e.g., “I’m losing control”), anxious predictions (e.g., “I’m going to fumble my words and humiliate myself”) and anxious beliefs (e.g., “Only weak people get anxious”).

2. physical: excessive physical reactions relative to the context (e.g., heart racing and feeling short of breath in response to being at the mall). The physical symptoms of anxiety may be mistaken for symptoms of a physical illness, such as a heart attack.

3. 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 (behaviours that aim to distract the person, e.g., talking more during periods of anxiety) and safety behaviours (habits to minimize anxiety and feel “safer,” e.g., 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 level of effect the anxiety symptoms have on a person’s ability to work or study, socialize and manage daily tasks
• the context in which the anxiety occurs.

An anxiety disorder may make people feel anxious most of the time or for brief intense episodes, which may occur for no apparent 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 immobilized. People with anxiety disorders are usually aware of the irrational and excessive nature of their fears. When they come for treatment, many say, “I know my fears are unreasonable, but I just can’t seem to stop them.”   Back to top

What are the different types of anxiety disorders?

The six main categories of anxiety disorders are phobias, panic disorder (with or without agoraphobia), generalized anxiety disorder, obsessive compulsive disorder, acute stress disorder and posttraumatic stress disorder*. Each of these anxiety disorders is distinct in some ways, but they all share the same hallmark features: 
• irrational and excessive fear
• apprehensive and tense feelings
• difficulty managing daily tasks and/or distress related to these tasks.

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-IV). Although each anxiety disorder can have many different symptoms, one representative example has been chosen to illustrate the typical cognitive, physical and behavioural symptoms of each disorder.

Panic disorder (with or without agoraphobia)
Description
• Panic disorder involves “repeated, unexpected panic attacks (e.g., heart palpitations, sweating, trembling) followed by at least one month of persistent concern about having another panic attack.”*
• Panic attacks may be accompanied by agoraphobia, when someone avoids or endures – with marked distress – specific situations, such as being outside the home alone, being in a crowd or standing in a line.

Examples of symptoms
Cognitive
• “I’m having a heart attack.”
• “I’m suffocating.”

Physical
• accelerated heart rate
• chest pain or discomfort
• dizziness or 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, malls, line-ups
• avoidance of strenuous activities (e.g., exercise)

Specific phobia
Description
• A specific phobia involves a “marked and persistent fear of clearly discernible, circumscribed objects or situations.”*
• 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; and other type, such as fear of choking or vomiting.

Examples of symptoms
Cognitive
• “This plane will crash.”
• “We are all going to die.”

Physical
• sweating
• muscle tension
• dizziness

Behavioural
• avoidance of air travel
• need to escape

Social phobia
Description
• Social phobia involves a “marked and persistent fear of social or performance situations in which embarrassment may occur.”*
• 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

Obsessive-compulsive disorder
Description
• Obsessive-compulsive disorder (OCD) involves “recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment.”*
• Obsessions are uninvited or “intrusive” thoughts, urges or images that surface in the mind over and over again, such as concerns about contamination (e.g., from touching door handles) or doubting (e.g., “Did I lock the door?”).
• Compulsions are behaviours or “rituals” that the person follows to try to reduce or suppress his or her obsessive thoughts (e.g., hand washing, checking).

Examples of symptoms
Cognitive
• “I’m going to get sick and infect the entire family if I touch this door handle.”

Physical
• muscle tension
• discomfort

Behavioural
• excessive washing, cleaning and/or checking
• avoidance of doors and public washrooms

Acute stress disorder
Description
• Acute stress disorder can occur after someone has “experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.”*
• The disorder occurs within one month of a traumatic event.
• Disturbing memories of the traumatic event cause an emotional reaction and a sense of reliving the event.

Examples of symptoms
Cognitive
• “I’m going to be trapped and die in a car crash.”
• “I’ve escaped being killed once – I won’t be so lucky a second time!”
• “The world is not safe.”

Physical
• restlessness, difficulty sleeping and concentrating
• exaggerated startle response
• feeling tense and on edge and/or numb

Behavioural
• avoidance of situations that arouse recollections of trauma
• intense emotional reaction or absence of emotional responsiveness

Posttraumatic stress disorder
Description
• Posttraumatic stress disorder (PTSD) involves the “development of characteristic symptoms following exposure to an extreme traumatic stressor.”*
• “The person’s response to the event must involve intense fear, helplessness, or horror.”*
• “Symptoms usually begin within three months of the trauma, although there may be a delay of months, or even years before the symptoms appear.”*
• The traumatic experience is repeatedly relived through intrusive memories, distressing dreams and flashbacks.

Examples of symptoms
Cognitive
• “I now realize that I’m never safe.”
• “People aren’t to be trusted.”

Physical
• sleep disturbance, nightmares
• irritability or outbursts of anger
• hypervigilance for danger

Behavioural
• avoidance of thoughts, feelings, conversations, activities, places or people associated with the trauma (e.g., emergency vehicles, parking lots)

Generalized anxiety disorder
Description
• Generalized anxiety disorder (GAD) involves “excessive anxiety and worry occurring more days than not for a period of at least six months, about a number of events or activities.”*.
• GAD is characterized by “difficulty in controlling worry.”*

Examples of symptoms
Cognitive
• “Something’s going to go wrong.”
• “This worry is going to make me nuts.”

Physical
• muscle tension
• inability to relax
• restlessness, irritability
• sleep disturbed by worry

Behavioural
• avoidance of news, newspapers
• restricted activities due to excessive worries about what could happen   Back to top

What causes anxiety disorders?

There are no clear-cut answers as to why some people develop an anxiety disorder, although research suggests that a number of factors may be involved. Like most mental health problems, anxiety disorders appear to be caused by a combination of biological factors, psychological factors and challenging life experiences, including:
• stressful or traumatic life events
• a family history of anxiety disorders
• childhood development issues
• alcohol, medications or illicit substances
• other medical or psychiatric problems.

Psychological factors
The two main schools of thought that attempt to explain the psychological influences on anxiety disorders are the cognitive and behavioural theories. A third way of looking at the psychological causes of anxiety is developmental theory, which seeks to understand our experience of anxiety as adults by looking at what we learn as children.

Cognitive theory: Cognitive theory suggests that people with anxiety disorders are prone to overestimate danger and its potential consequences. For example, people may overestimate the danger of particular animals, such as spiders or snakes, and thus believe that harm from that animal is far greater and more common than it actually is. Thinking of the worst possible scenario, they may imagine that a snake will bite and poison them, when it may be completely harmless. This is known as catastrophizing, and is common among people with anxiety disorders.

Behavioural theory: Behavioural theory suggests that people learn to associate the fear felt during a stressful or traumatic life event with certain cues, such as a place, a sound or a feeling. When the cues reoccur, they cause the fear to be re-experienced. Once the association between the fear and the cue is learned, it is automatic, immediate and out of conscious control. The fear is felt before there is time to tell if danger is near.

Developmental theory: According to developmental theory, the way in which children learn to predict and interpret life events contributes to the amount of anxiety they experience later in life. The amount of control people feel over their own lives is strongly related to the amount of anxiety they experience. People who feel that life is out of their control are likely to feel more fear and anxiety.

Biological factors
The biological causes and effects of anxiety disorders include problems with brain chemistry and brain activity; genetics; and medical, psychiatric and substance use issues.

Brain chemistry and brain activity: Research has revealed a link between anxiety and problems with the regulation of various neurotransmitters – the brain’s chemical messengers that transmit signals between brain cells. Three major neurotransmitters are involved in anxiety: serotonin, norepinephrine and gamma-aminobutyric acid (GABA). Modern brain-imaging techniques have allowed researchers to study the activity of specific areas of the brain in people with anxiety disorders.

Genetic factors: Research confirms that genetic factors play a role in the development of anxiety disorders. People are more likely to have an anxiety disorder if they have a relative who also has an anxiety disorder. The incidence is highest in families of people with panic disorder, where almost half have at least one relative who also has the disorder.

Medical factors:
• Alcohol, medications and illicit substances: Substance use may induce anxiety symptoms, either while the person is intoxicated or when the person is in withdrawal.
• Medical conditions: A range of medical conditions can cause anxiety symptoms and result in anxiety disorders.
• Psychiatric conditions: People with other psychiatric disorders often also have symptoms of anxiety. Sometimes it is the symptoms of the other disorder, such as depression or psychosis, that heighten a person’s anxiety. In such cases the person may not be diagnosed as having an anxiety disorder.   Back to top

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How are anxiety disorders treated?

Many psychological treatments – such as relaxation training, meditation, biofeedback and stress management – can help with anxiety disorders. Many people with anxiety disorders also benefit from supportive counselling or couples or family therapy. However, experts agree that the most effective form of treatment for the anxiety disorders is cognitive-behavioural therapy (CBT). Medications have also been proven effective, and many people receive CBT and medication in combination.

Cognitive-behavioural therapy
CBT is a brief, problem-focused approach to treatment based on the cognitive and behavioural aspects of anxiety disorders. Typically, CBT consists of 12 to 15 weekly one-hour sessions.

What does CBT involve?

A standard component of CBT treatment is exposure therapy, which involves gradually exposing the person, either directly or through the person’s imagination, to his or her feared situation that triggers anxiety.

The rationale behind exposure therapy is that by practising exposure to their fears, people have the opportunity to learn that their fears are excessive and irrational, and that the anxiety decreases with more and more practice.

An important part of CBT is helping people with anxiety disorders to identify, question and correct their tendencies to overestimate danger and their perceived inability to cope with danger.

With repeated practice in therapy and then as part of homework, people with anxiety disorders develop skills that enable them to identify anxiety-related thoughts and beliefs, identify common distortions in their thinking, examine the evidence that supports and does not support their fearful appraisals, and develop less-threatening alternative responses to the feared object or situation.

CBT has been found to be effective for all the anxiety disorders. Most people experience a significant reduction in their symptoms and stay well after the treatment ends. Given the success of this therapy and its ability to reduce relapse, CBT is established as the first-choice psychological treatment for anxiety disorders.

Medication options
Research has shown that people with anxiety disorders often benefit from medications that affect various neurotransmitters, particularly serotonin, norepinephrine and GABA. Medications can help reduce symptoms of anxiety, especially when combined with CBT.

The main medications used to treat anxiety are selective serotonin reuptake inhibitors (SSRIs), norepinephrine and serotonin reuptake inhibitors (NSRIs) and benzodiazepines (BZDs). SSRIs and NSRI's belong to a class of drugs called “antidepressants,” which are commonly prescribed to treat both anxiety disorders and depression. Benzodiazepines are classed as “sedatives” and are generally used to treat anxiety or insomnia.

Doctors treating anxiety disorders will usually prescribe an SSRI or an NSRI. Research indicates that these medications help reduce the symptoms of anxiety for about 70 per cent of the people who take them. For those who do not benefit from taking an SSRI or NSRI, other drug treatments can provide relief. In some cases, specific symptoms of anxiety may be addressed with other medications, such as “beta blockers” to reduce hand tremors or slow down the heart rate, or “anticholinergics” to reduce sweating. Such medications can be taken in addition to an SSRI or NSRI.   Back to top

What about recovery?

When someone begins treatment for an anxiety disorder, the first goal is to reduce and manage symptoms. The process of achieving this goal, known as “recovery,” often includes a combination of medication, cognitive-behavioural therapy (CBT) and supportive psychotherapy, and may also include other support such as occupational, recreation and nutrition therapy. Recovery also includes the way you apply the skills learned in treatment to real life situations. Your idea of what you hope to achieve through recovery is unique to you. Long-term goals may include improved relationships with others, a full and satisfying work life, increased self-esteem and improved overall quality of life.

Once recovery is underway, and you are ready to focus on getting your life back to normal, the next step is “relapse prevention.” Anxiety is not an illness with a “cure.” Medication and therapy can help to bring symptoms under control, but some of the symptoms of anxiety, such as worry and fear, can arise for anyone during everyday life. To prevent relapse, you need to be ready with a plan to manage symptoms as they appear. Moving through the process of recovery and relapse prevention depends on a combination of planning and attitude. Achieving and maintaining your goals is easier when you develop:
• awareness of warning signs and strategies to respond to setbacks
• a healthy lifestyle
• hope and optimism about the future
• self-confidence.   Back to top

Anxiety disorders: Help for partners and families

What happens when someone you love has an anxiety disorder?

When someone in a family has an anxiety disorder, everyone is affected. Having someone with an anxiety disorder in the family brings added pressures. Because most people experience some degree of anxiety in life, it may be quite some time before your relative receives an accurate diagnosis and begins to receive treatment.

It is natural for families and partners to feel resentful or disappointed when anxiety interferes with normal family life. Acknowledging the illness can be the first step toward understanding and making the family work again.

How to relate to your family member
1. Learn as much as you can about the symptoms of and treatments for your relative’s anxiety disorder.
2. Encourage your family member to follow the treatment plan.
3. Try to keep anxiety from taking over family life.
4. Be supportive of your relative, without supporting his or her anxiety.
5. Communicate with your relative positively, directly and clearly.
6. Applaud your relative’s progress at confronting anxiety and encourage him or her to use skills learned in treatment to manage symptoms.

Taking care of yourself
When family members or partners are caught up in caring for a relative with an anxiety disorder, they may neglect to take care of themselves. At times they may give up their own activities and become isolated from friends and colleagues. The isolation could go on for some time before they realize how emotionally and physically drained they are from caring for their relative or partner. The stress can result in disturbed sleeping patterns, feelings of irritability and/or episodes of exhaustion.

Family caregivers or partners need to be aware of their personal signs of stress and know their personal limits. They need to take actions to maintain their physical and mental health. Taking time out for oneself and keeping up interests outside of the family, and apart from the relative with an anxiety disorder, can help the family caregiver to recharge. Recovery from an anxiety disorder can be a long process. Caregivers need to set aside feelings of guilt, or of pressure to focus always on the relative who needs help. When caregivers take the time to have their own needs met, they have more energy and patience to support their relative, and are less likely to feel resentful or overwhelmed.

Family and friends can offer valuable support. However, when seeking such support, it is important to be aware that some people are more informed and understanding about mental health problems than others. It is wise to be selective when choosing who to confide in, and what advice to follow.

Family caregivers are encouraged to seek professional support that is specific to families of people with mental health problems. Support could include individual or family counselling, family support and education groups to improve understanding of their relative’s anxiety disorder, and self-help groups where families of people with anxiety disorders provide support to each other. Counselling and groups may be offered by a community hospital, clinic or mental health organization.
Explaining anxiety disorders to children

It can be challenging to explain anxiety disorders to children. Sometimes parents will not tell their children that a family member has been diagnosed with an anxiety disorder and will continue with family routines as if nothing was wrong.

But because children are sensitive and intuitive they will notice when a member of the family has emotional, mental and physical changes. Parents should avoid being secretive about the relative’s anxiety disorder, as children will develop their own—often wrong—ideas about their relative’s condition.

To explain anxiety disorders to children, it is important to provide them with only as much information as they are mature or old enough to understand. When providing information to toddlers and preschool children, parents should use simple, short sentences. That is, the sentences should be worded in concrete language and be free of technical information. For example, “Sometimes your father doesn’t feel well and it makes him upset.” Or, “Your father has an illness that makes him feel upset when he sees someone climb a ladder.”

Children in elementary school can process more information. They are more able to understand the concept of an anxiety disorder as an illness; however, too much detail about the nature of the illness and how it is being treated could overwhelm them. One way to explain anxiety disorders to elementary school children is to say, “An anxiety disorder is a kind of illness that makes people worry a lot about heights and getting sick. Worrying so much makes them avoid tall buildings.”

Teenagers can manage most information, and often need to talk about what they see and feel. They may worry about the stigma of mental health problems and may ask about the genetics of anxiety disorders. Teenagers will engage in conversations about anxiety disorders if information is shared with them.

There are three main areas that are helpful for parents to cover when speaking with children about anxiety disorders:
1. The parent or family member behaves this way because he or she has an illness.
2. Reassure the child that he or she did not make the parent or family member get this illness.
3. Reassure the child that the adults in the family and other people, such as doctors, are trying to help the affected person.

When the relative with an anxiety disorder is in recovery, it helps for the person to explain his or her behaviour to the children. The recovered relative may need to plan some special times with the children to re-establish their relationship and reassure the children that he or she is now more available to them.   Back to top

Adapted from Anxiety Disorders: An Information Guide © 2009, Centre for Addiction and Mental Health 

* American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.