Anxiety disorders: Overview​

Key points

• Anxiety describes a range of conditions with symptoms of fear and worry that are difficult to control and that interfere with day-to-day life. Symptoms typically last more than six months.
• Anxiety disorders are the most common of all mental illnesses, affecting 12% of adults aged 15–64. About 16% of women and 9% of men have an anxiety disorder.

Types of anxiety

Generalized anxiety disorder (GAD)

Generalized anxiety disorder (GAD) features excessive worry about events or activities that occurs more days than not over a period of at least six months. The person finds it hard to control the anxiety, which causes significant distress or impairment in social, occupational or other important areas of functioning.

Three or more of the following symptoms must be present to make a diagnosis of GAD (only one symptom is required for children):

• restlessness or feeling keyed-up or on edge
• being easily fatigued
• difficulty concentrating or mind goes blank
• irritability
• muscle tension
• sleep disturbances (difficulty falling or staying asleep, or restless sleep).

Panic disorder

Panic disorder features recurrent, unexpected panic attacks.

Four or more of the following 13 symptoms develop abruptly with a panic attack and reach a peak within minutes:

• palpitations, pounding heard or accelerated heat rate
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, lightheaded or faint
• derealization (feelings of unreality) or depersonalization (being detached from oneself)
• fear of losing control or going crazy
• fear of dying
• paresthesias (numbness or tingling sensations)
• chills or hot flashes.

Agoraphobia

Agoraphobia is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of a panic attack or panic-like symptoms. Such situations are avoided or endured with marked distress or anxiety. Fear or avoidance typically lasts six months or more and causes significant distress.

Symptoms of agoraphobia include:

• fear or anxiety in at least two of the following situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, being outside of the home alone
• fear or avoidance of situations that might lead to a panic attack.

Social phobia (social anxiety disorder)

Social phobia features a marked and persistent fear or anxiety about social situations where the person may be embarrassed, humiliated or scrutinized. These situations may include public speaking or performance, meeting strangers, dating or eating in public. In children, this anxiety must occur with peers, not just with adults.

Symptoms of social phobia include:

• physical symptoms such as blushing, sweating, dry mouth, rapid heart beat, trembling or shaking
• avoidance of social situations or experiencing intense fear or anxiety in these situations
• in children, the anxiety is expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations.

Specific phobia

Specific phobia involves fear or anxiety about a specific object or situation. Common phobias include flying, elevators, animals or insects, storms, seeing blood and getting injections.

Symptoms include:

• fear, anxiety or avoidance of the phobic object
• significant distress related to the object.

Separation anxiety

Separation anxiety is inappropriate, excessive and persistent fear or anxiety about separation from those to whom the person is attached.

At least three of the following symptoms must be present to make the diagnosis:

• distress when anticipating or experiencing separation from home or attachment figures
• worry about something happening that causes separation from the attachment figure
• reluctance or refusal to leave home because of fear of separation
• fear about being home along without the attachment figure
• reluctance or refusal to sleep away from home without being near the attachment figure
• repeated nightmares about separation
• physical symptoms such as headaches, stomach aches, nausea or vomiting when separation from attachment figures is anticipated.

Selective mutism

Selective mutism is the consistent failure to speak in specific social situations where the person is expected to speak, despite having no or little difficulty speaking in other situations. Selective mutism lasts at least one month and interferes with the person's work or school performance, or with social interaction. It is more common in young children than adolescents and adults.

Substance/medication-induced anxiety

Substance/medication-induced anxiety is the direct consequence of using a medication or drug of abuse, or of being exposed to a toxin.

Symptoms include panic attacks or anxiety that develop during or soon after substance intoxication or withdrawal, or after exposure to a medication.

A DSM-5 update about anxiety disorders

Obsessive-compulsive disorder (OCD) was included in the anxiety chapter in the DSM-IV. In the DSM-5, OCD is part of a new chapter called Obsessive-Compulsive and Related Disorders. Also, posttraumatic stress disorder (PTSD) and acute stress disorder are included in a new chapter called Trauma-and-Related Stress Disorders.

Causes

Genetic and family history

• Anxiety tends to run in families.
• People who have family members with an anxiety disorder have a general vulnerability to develop an anxiety disorder rather than a particular anxiety disorder.
• Almost half of people with panic disorder have at least one family member with the disorder.

Environmental factors

• People learn to associate stressful or traumatic events with cues, such as a place, feeling or sound. When the cue occurs, the person automatically re-experiences the fear he or she felt during the original event. People with anxiety disorders may go to great lengths to avoid those cues.
• High levels of family tension during childhood can trigger anxiety and unhealthy ways of coping that increase the likelihood of anxiety disorders.
• Children who grow up with parents who are anxious and avoidant may learn unhealthy ways of coping and are more likely to develop an anxiety disorder.

Biological factors

• Research has shown a link between anxiety and problems with the regulation of certain neurotransmitters, including serotonin, norepinephrine and gamma-aminobutyric acid.
• Brain-imaging studies have shown abnormalities in cerebral blood flow and metabolism, as well as structural abnormalities.

Medical factors

• Panic and generalized anxiety symptoms may result from medical conditions, particularly those of the glands, heart, lungs or brain. Treatment of the medical condition reduces the anxiety.
• Strep and other infections can lead to obsessive-compulsive symptoms.
• People with anxiety symptoms often have other psychiatric disorders, which may be the cause of their anxiety.
• Substance use may induce anxiety symptoms, particularly stimulants such as caffeine, cocaine and Ritalin.

Prognosis

• Early recognition and management are key to recovery and can prevent secondary disorders such as depression and substance use problems.
• Stigma, lack of knowledge or financial resources, or lack of access to health care professionals may discourage people from seeking help.
• Anxiety disorders can be managed well in the primary care setting with access to experts in cognitive-behavioural therapy.

Evidence summary

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

Laposa, J, (2012). Anxiety disorders. In A. Khenti, J. Sapag, S. Mohamound & A. Ravindran, A. (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 115–126). Toronto, ON: Centre for Addiction and Mental Health.

Rector, N., Bourdeau, D., Kitchen, K. & Joseph-Massiah, L. (2008). Anxiety Disorders: An Information Guide. Toronto, ON: Centre of Addiction and Mental Health.

Swinson, R. (2011). The patient who is anxious. In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 45–60). Toronto, ON: Centre for Addiction and Mental Health.