Anxiety Disorders

Everyone experiences anxiety—worry, nervousness, or unease—from time to time. But for people with anxiety disorders, this fear is disproportionate, all-consuming, and severely impacts their lives. People with anxiety disorders may fear social interaction, crowds, specific things such as spiders or elevators, separation from their loved ones or home, or worry about a range of things.

What are anxiety disorders?

Anxiety disorders are a group of mental disorders marked by persistent or episodic fear and worry, disproportionate to actual danger and impairing everyday functioning. Individuals may avoid situations that trigger anxiety and experience physical and cognitive symptoms such as increased heart rate, chest pain, fatigue, and difficulty concentrating.

Anxiety disorders are the most common mental disorders in the world, with a global prevalence of 7.3%.[1]

Get help during covid-19

Get help during Covid-19

At Recovered, we recognize the impact COVID-19 has had and the continued challenges it poses to getting advice and treatment for substance use disorders. SAMHSA has a wealth of information and resources to assist providers, individuals, communities, and states during this difficult time and is ready to help in any way possible.

Speak to SAMSHA

Types of anxiety disorders

There are multiple types of anxiety disorders:

Generalized anxiety disorder (GAD)

Generalized anxiety disorder is characterized by excessive, often irrational worry about many things, persisting for at least six months and affecting everyday functioning. It’s also marked by restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and difficulty sleeping.

Generalized anxiety disorder is distinguished from other anxiety disorders by the widespread nature of worries.

Panic disorder

In panic disorders, people have recurring, sudden episodes of intense fear or discomfort. These panic attacks may be triggered by stress, a specific or general fear, or even exercise but sometimes they have no discernible cause. They typically come on suddenly, peaking within 10 minutes, but may last up to several hours. During a panic attack, an individual may have a feeling of impending doom and the urge to run away.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), panic attacks must have at least four of the following symptoms:

  • Pounding or racing heart, palpitations

  • Sweating

  • Trembling or shaking

  • Shortness of breath or feeling of suffocation

  • Feeling of choking

  • Nausea or abdominal discomfort

  • Feeling dizzy, light-headed, faint, or steady

  • Feeling chilled or overheated

  • Paresthesias such as tingling or numbness

  • Depersonalization (feeling of being detached from the self, watching the self from the outside)

  • Fear of losing control or going crazy

  • Fear of dying[2]

Other symptoms may include headache, diarrhea, insomnia, intrusive thoughts, rumination, and fatigue.

Social anxiety disorder

Also known as social phobia, social anxiety disorder involves overwhelming fear and avoidance of social situations in which they’ll be exposed to unfamiliar people or possible scrutiny. People with social anxiety disorder fear negative evaluations from others—that they’ll be humiliated, embarrassed, rejected, or cause offense. 

To be diagnosed as social anxiety, the symptoms must last for at least six months, not be explained by another mental disorder such as panic disorder or autism, and cause significant distress or impairment in relationships, work, and other important areas of functioning.[3]

Social anxiety may cause physical symptoms such as blushing, difficulty speaking, sweating, and accelerated heart rate.

Specific phobia

A specific phobia is an extreme, unreasonable fear of something that poses little or no threat. Exposure to the thing, or even thinking about it, can provoke symptoms of anxiety, which range from mild fear to intense panic attacks, fainting, and loss of bowel or bladder control. The individual may go to great lengths to not be exposed to the subject of their phobia.

Many people are fearful of certain things, but it’s diagnosable as a phobia if it interferes with your daily functioning for at least six months.

The DSM-5 lists five types of phobias:

  • Animal: spiders (arachnophobia), dogs (cynophobia), insects (entomophobia), snakes (ophidiophobia), mice and rats (musophobia)

  • Natural environment: heights (acrophobia), the ocean or deep water (thalassophobia), thunder and lightning (astraphobia)

  • Blood-injection-injury: blood (homophobia), needles (trypanophobia)

  • Situational: confined spaces (claustrophobia), flying in an airplane (aerophobia), elevators,

  • Other: such as vomiting (emetophobia), swallowing, or choking (pseudodysphagia)[4]

Phobias are the most common anxiety disorder: an estimated 9.1% of U.S. adults experience one in any year and 12.5% will have a phobia at some point in their life.[5] Around three-quarters of people with phobias have more than one.[4]

Agoraphobia

In agoraphobia, an individual has fear or anxiety about situations in which escape may be difficult or help might not be available in the event of panic or other incapacitating or embarrassing symptoms.

The DSM-5 says the individual must have anxiety about at least two of the following five situations:

  • Public transportation such as cars, buses, trains, and planes

  • Open spaces such as parking lots and malls

  • Enclosed spaces such as stores, cinemas, and theatres

  • Crowds or lines

  • Being outside of the home alone[6]

Separation anxiety

Individuals with separation anxiety experience undue anxiety about being separated from their home and/or from people they have a strong emotional attachment to, such as their parents, significant others, or siblings. Separation anxiety was once classified as a juvenile disorder, but recent research suggests it can occur in adults.[7]

Selective mutism

Selective mutism is an anxiety disorder in which someone otherwise capable of speech becomes unable to speak in certain situations, such as at school or to relatives they don’t frequently see. These situations trigger a freeze response and feelings of panic that render them incapable of talking.

Selective mutism usually begins in childhood but can continue into adulthood if it’s untreated.

Health anxiety

Health anxiety, or hypochondria, is an obsessive, irrational worry about having a serious illness. The worry persists despite negative testing and reassurance from medical professionals. Often the individual fixates on ordinary or minor bodily sensations and believes they are symptoms of a serious condition.

Others

Sometimes obsessive-compulsive disorder, acute stress disorder, and post-traumatic stress disorder (PTSD) are classified as anxiety disorders.

Symptoms of anxiety disorders

Symptoms of anxiety disorders may include:

  • Nervousness

  • Excessive and uncontrollable worry

  • Panic

  • Obsessive thoughts

  • Feeling on edge or restless

  • Racing or pounding heart

  • Sweating

  • Shortness of breath

  • Chest pain

  • Muscle tension

  • Numbness or tingling in hands or feet

  • Trembling and shakiness

  • Nausea

  • Blushing

  • Avoiding situations that cause anxiety

  • Insomnia

  • Difficulty concentrating

  • Fatigue

  • Irritability

How are anxiety disorders diagnosed?

If you believe you have an anxiety disorder, you should speak to your primary care physician first. They will ask you about your symptoms and may run or order tests that can rule out physical causes (such as hyperthyroidism, cardiac problems, or substance abuse). If they suspect your problems are psychological, they’ll refer you to a psychiatrist or psychologist. 

These mental health professionals will ask you questions about your symptoms, your stress levels, your history of physical or emotional trauma, and your family history of mental illness. They may have you fill out questionnaires such as the Generalized Anxiety Disorder Assessment (GAD-7) or the Panic Disorder Severity Scale (PDSS). They will refer to the criteria in the DSM-5 when making their diagnosis.[8]

What causes anxiety disorders?

Anxiety disorders likely emerge from a confluence of genetic and environmental factors. Multiple risk factors have been linked to an increased vulnerability to anxiety, including:

  • Genetics: Anxiety disorders are thought to be about 30% inherited.[9] Having a first-degree relative with an anxiety disorder can increase the risk of developing one yourself by 2 to 7 times.[10] Several anxiety disorders, including generalized anxiety disorder, panic disorder, and social anxiety disorder have been linked to specific genes.[11] 

  • Trauma: physical, sexual, or emotional.

  • Childhood adversity: including abuse and neglect, domestic violence, parental alcoholism or drug use, parental mental health problems, overprotective or overly harassing parenting, and bullying from peers.[12]

  • Sex: Anxiety disorders are 1.5 to 2 times as prevalent in females than in males.[13]

  • Other mental health problems: including depression and other anxiety disorders.

  • Chronic physical medical conditions: including cancer, cardiovascular disease, diabetes, and arthritis.[12]

  • Personality traits: including shyness, sensitivity to criticism, obsession with details, and morality rigidity.[14]

What treatment options are there for anxiety disorders?

Anxiety disorders are typically treated with a combination of lifestyle changes, medication, and psychotherapy.

Lifestyle changes

Some people may be able to manage their anxiety just by making changes to their lifestyle and diet, including:

  • Regular exercise

  • Maintaining a regular sleep schedule

  • Reducing caffeine intake

  • Quitting smoking[15]

Medication

The first-line medications for anxiety disorders are antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Around 30% to 50% of patients respond to them. 

Patients for whom antidepressants don’t work may be prescribed buspirone, the anticonvulsants pregabalin and gabapentin, or the antipsychotic quetiapine. Benzodiazepines can be effective for treating GAD but there is concern about misuse and dependence and they should only be prescribed in the short term.[15] Beta-blockers can reduce the physical symptoms of anxiety, including sweating, shaking, and rapid heartbeat.[16]

Psychotherapy

Multiple psychotherapeutic techniques have been used and studied for anxiety disorders, including:

  • Cognitive behavioral therapy (CBT): CBT helps patients recognize, challenge, and modify unhelpful patterns of thought and behavior that reinforce their anxiety disorder, including overestimating the level of danger, ruminating, catastrophizing, and avoiding certain situations.

  • Psychodynamic therapies: address the underlying conflicts that are thought to be the root of anxiety.

  • Acceptance and commitment therapy (ACT): a mindfulness-based therapy that helps patients accept unpleasant feelings, not overreact, and not avoid situations in which they encounter these feelings. Patients are encouraged to focus on the present. It’s particularly useful for social anxiety disorder.[15]

  • Exposure therapy: a form of CBT particularly useful for phobias. Patients are exposed to the thing they fear, either actually or increasingly through virtual reality, and try not to engage in safety behaviors such as distraction or reassurance seeking. Through repeated exposure, they become desensitized. Exposure therapy can help up to 90% of patients with phobias, however, dropout rates are high.[17]

Anxiety disorders and substance abuse

The relationship between mental health disorders and substance abuse is multifaceted and reciprocal. 

Anxiety is a risk factor for substance abuse and dependence and vice versa. For example, generalized anxiety disorder increases the risk of alcohol dependence by 2.8 times and the risk of drug dependence by 9.5. The presence of panic disorder with agoraphobia increases the risk of alcohol dependence by 3.5 times and drug dependence by 9.2 times. Specific phobias, social anxiety, and panic disorder without agoraphobia also increase vulnerability to substance dependence.[18]

Substance use can trigger anxiety disorders. However, research indicates that this is quite rare, accounting for only 0.2% of comorbid cases. Instead, the anxiety disorder predates substance abuse in at least 75% of cases. This suggests that many people with anxiety disorders use substances to self-medicate their symptoms.[18]

Some anxiety disorders are associated with particular types of substance abuse. For instance, around a fifth of those with social anxiety disorder [SAD] abuse alcohol, with many saying drinking is their largest coping mechanism besides avoiding social situations. Social anxiety leads to a heightened risk of relapse among those who have quit drinking.[19]

Anxiety disorders and substance abuse may also occur separately in the same individuals as they have overlapping risk factors, including childhood adversity, traumatic experiences, and other mental health conditions.

Regardless of which disorder led to the other, anxiety and substance abuse mutually reinforce each other, complicate treatment for the other, and lead to worse outcomes. For example, anxiety disorders have been linked to greater severity of alcohol use disorder, increased severity of alcohol withdrawal, and higher relapse rates following treatment.[18] Conversely, alcohol or other substance abuse decreased the likelihood of recovery from generalized anxiety disorder by fivefold and increased the likelihood of recurrence by threefold.[20] 

That’s why the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Psychiatric Association (APA) recommend that anxiety disorders and substance use disorders be treated simultaneously, often using the same team of professionals and multiple therapeutic and medicinal interventions.

Many medications for anxiety disorders, including antidepressants, can be safely prescribed to those with a history of substance abuse as they have no risk of addiction. However, these individuals shouldn’t be prescribed potentially addictive benzodiazepines.

Getting help for anxiety disorders

While many anxiety disorders are chronic conditions, therapy and medication can significantly improve symptoms and patients' quality of life.

The National Alliance on Mental Illness (NAMI) can point you to doctors and therapists, resources, and support such as groups in your area. Contact the NAMI HelpLine at 1-800-950-NAMI (6264) or by emailing [email protected].

The Anxiety and Depression Association of America (ADAA) offers an anonymous peer-to-peer online anxiety support group. It can also direct you to qualified therapists.