Summary
Highlights
Anxiety is a future-oriented mood state characterized by the anticipation of danger, misfortune, or adverse events, leading to tension and negative emotions. While anxiety and fear (a present-oriented mood state activating fight-or-flight) are normal, they become problematic when they prevent achievement. Anxiety disorders are pervasive and persistent, involving intense worry, avoidance, and significant distress or impairment. Panic attacks are abrupt, intense experiences of fear accompanied by physiological (e.g., heart palpitations, sweating) and cognitive symptoms (e.g., fear of losing control or dying), categorized as expected or unexpected. The DSM-5 outlines specific criteria for panic attacks, requiring at least four physiological or cognitive symptoms within minutes.
Biological factors contributing to anxiety include genetic vulnerabilities, depleted neurotransmitter levels (e.g., GABA, norepinephrine, serotonin), and activation of the fight-or-flight, behavioral inhibition, or limbic systems. Psychological contributions stem from early childhood experiences of uncontrollability and unpredictability, stressful life events, and learned responses (behavioral conditioning). Catastrophic thinking and negative appraisals (cognitive factors) also play a significant role. The triple vulnerability model integrates these factors: biological (heritable negative affectivity), generalized psychological (sense of uncontrollability/unpredictability, low self-esteem), and specific psychological (anxiety about physical sensations).
Comorbidity, having multiple psychological diagnoses, is common with anxiety disorders; major depression is the most frequent co-occurring disorder. While not all anxious individuals are depressed, and vice-versa, common underlying factors exist. Generalized Anxiety Disorder (GAD) is characterized by chronic, excessive, and uncontrollable worry about multiple aspects of life, persisting for at least six months and accompanied by physiological arousal. GAD affects about 3% of the population, with females outnumbering males two to one. Onset is insidious, often in early adulthood, and it is prevalent among the elderly and tends to run in families. Treatment options include Cognitive Behavioral Therapy (CBT) and psychotropic medications like benzodiazepines and antidepressants, though treatment success is often weak without active coping skill practice.
Panic disorder involves recurrent, unexpected panic attacks and persistent worry or fear about having future attacks. Agoraphobia, a common comorbidity, is the fear of situations where escape might be difficult or help unavailable, often leading to avoidance of public spaces. Panic disorder affects about 2.7% of the population, with acute onset between ages 20-24. Agoraphobia is also more prevalent in females. Risk factors include high emotional reactivity to stress, physical alarm reactions, and believing bodily sensations are dangerous. Treatment involves medication (benzodiazepines, SSRIs), though relapse rates are high upon discontinuation, and Cognitive Behavioral Therapy (CBT), particularly Panic Control Treatment (PCT), which involves intentionally triggering panic symptoms to build tolerance. CBT alone often yields better long-term outcomes than medication.
Specific phobias are irrational fears of particular objects or situations, leading to significant avoidance and interference with functioning, despite the individual recognizing the fear as unreasonable. They affect about 12.5% of the population and are chronic, with females being four times more likely to be affected. Common phobias include animals, natural environments, situations, and blood-injection-injury. Causes involve direct experiences, biological/evolutionary vulnerabilities, and learned behaviors. CBT is highly effective. Social Anxiety Disorder (SAD) involves extreme fear or discomfort in social or performance situations, leading to avoidance or significant distress. Affecting about 12% of the population, it's more prevalent in females and typically begins in adolescence (peak age 13). Causes include biological and evolutionary vulnerabilities, similar to specific phobias. CBT and group therapy are effective, and medications like SSRIs or beta-blockers may be used.
Selective mutism, a rare childhood disorder, is characterized by a consistent lack of speech in specific social situations despite speaking in others, often co-occurring with social anxiety disorder. Treatment is primarily behavioral therapy. The DSM-5 introduced a new category for Trauma- and Stressor-Related Disorders, including PTSD, Acute Stress Disorder, Adjustment Disorders, and Attachment Disorders. Post-Traumatic Stress Disorder (PTSD) involves re-experiencing a traumatic event, avoidance, emotional numbing, and interpersonal problems, lasting for over a month. While combat and sexual assault victims are common reporters, anyone experiencing trauma can develop PTSD, with about 7% of people experiencing it at some point. Causes include trauma intensity, learning, biological vulnerabilities, uncontrollability, and lack of social support. CBT, often involving exposure, is the most effective treatment, sometimes combined with SSRIs for anxiety and panic.
Adjustment disorders are milder than PTSD, occurring when anxiety or depression results from life changes or stressors, causing clinically significant distress. Attachment disorders in children, such as Reactive Attachment Disorder (emotional withdrawal) and Disinhibited Social Engagement Disorder (indiscriminate social behavior), arise from inadequate or neglectful early care. The DSM-5 also established a new category for Obsessive-Compulsive and Related Disorders, including OCD, Hoarding Disorder, Body Dysmorphic Disorder, Trichotillomania (hair pulling), and Excoriation (skin picking). Obsessive-Compulsive Disorder (OCD) features intrusive obsessions (recurrent thoughts) and compulsions (repetitive behaviors) such as cleaning, washing, or checking. It affects about 2% of the population equally across genders and cultures, typically starting in early adolescence or young adulthood, and tends to be chronic. Causes parallel other anxiety disorders, involving early life experiences and negative thought patterns. SSRIs are used, but relapse is common upon discontinuation. Psychosurgery is reserved for extreme cases. CBT, including exposure and response prevention, is highly effective, often more so than medication alone.
Body Dysmorphic Disorder (BDD), a new DSM-5 disorder, entails preoccupation with an imagined or slight flaw in one's physical appearance, causing significant distress and leading to compulsive behaviors (e.g., repeatedly checking appearance, seeking plastic surgery). It affects 1-2% of the general population and 4-28% of college students, often experienced equally by males and females. BDD tends to be long-term, potentially worsened by social media. Treatment mirrors OCD, with CBT and anxiety-reducing medications offering some relief, though plastic surgery often doesn't resolve the underlying issue. Hoarding Disorder involves excessive collecting and difficulty discarding possessions, regardless of value, leading to cluttered living spaces and social impairment. Trichotillomania is the compulsive urge to pull one's hair, while excoriation is the repetitive and compulsive picking of the skin, both leading to tissue damage. Behavioral therapy, particularly habit reversal training, is effective for these behavioral disorders.
Anxiety and related disorders occur when natural adaptive processes like anxiety, fear, and panic become disproportionate to environmental demands. These disorders are influenced by biological, generalized psychological, and specific psychological vulnerabilities. This chapter covered Generalized Anxiety Disorder, Panic Disorder, Agoraphobia, Specific Phobias, Social Anxiety Disorder, Selective Mutism; Trauma- and Stressor-Related Disorders like PTSD, Acute Stress Disorder, Adjustment Disorders, and Attachment Disorders; and Obsessive-Compulsive and Related Disorders, including OCD, Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, and Excoriation. For most anxiety disorders, Cognitive Behavioral Therapy (CBT) is considered the most effective treatment, while medication can be helpful but often leads to relapse if discontinued.