Anxiety is a natural part of life and, at normal levels, helps us to function at our best. However, for people with anxiety disorders, anxiety is overwhelming and difficult to control. Anxiety disorders develop from a mixture of biological (genetic) and psychological factors which, when combined with stress, can lead to the development of illness. Primary anxiety-related diagnoses include generalised anxiety disorder, panic disorder, various specific phobias, social anxiety disorder (social phobia), post-traumatic stress disorder and obsessive-compulsive disorder.
But what is Anxiety?
What is anxiety? Most of us experience anxiety almost every day of our lives. Maybe there's an important test coming up for that tricky subject at university. Or maybe there's that big match next Saturday, or that first date with someone new we're hoping to impress. Anxiety can be defined as a negative mood state that is accompanied by bodily symptoms such as increased heart rate, muscle tension, feelings of unease and apprehension about the future (1).
Anxiety is what motivates us to plan for the future and, in this sense, anxiety is actually a good thing. It's that nagging feeling that motivates us to study for that test, train harder for that game or give our best at that meeting. But some people experience anxiety so intensely that it's no longer useful. They can become so overwhelmed and distracted by anxiety that they end up failing a test, getting that pass wrong or missing an open goal, or spending the whole match thinking about other things and avoiding eye contact. If anxiety starts to interfere with a person's life in a significant way, it's considered a disorder.
Anxiety and closely related disorders emerge from "triple vulnerabilities", a combination of biological, psychological and specific factors that increase our risk of developing a disorder (1). Biological vulnerabilities refer to specific genetic and neurobiological factors that can predispose someone to developing anxiety disorders. No single gene directly causes anxiety or panic, but our genes can make us more susceptible to anxiety and influence the way our brain reacts to stress (2, 3). Psychological vulnerabilities refer to the influences that our early experiences have on the way we see the world. If we were confronted with unpredictable stressors or traumatic experiences at a younger age, we may come to see the world as unpredictable and uncontrollable, even dangerous (4). Specific vulnerabilities refer to how our experiences lead us to focus and channel our anxiety (5). If we have learnt that physical illness is dangerous, perhaps through witnessing our family's reaction whenever someone falls ill, we can focus our anxiety on physical sensations. If we have learnt that physical illness is dangerous, perhaps by witnessing our family's reaction whenever someone falls ill, we can focus our anxiety on the physical sensations. If we learn that the disapproval of others has negative or even dangerous consequences, such as being shouted at or severely punished for even the smallest offence, we can focus our anxiety on social evaluation. If we learn that "anything can go wrong" at any time, we can focus our anxiety on worries about the future. None of these vulnerabilities directly causes anxiety disorders on their own - instead, when all these vulnerabilities are present, and we experience some triggering stress in life, the result can be an anxiety disorder (5). In the following sections, we will briefly explore each of the main anxiety-based disorders found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Generalised Anxiety Disorder
Most of us worry with some frequency, and this worry can be useful to help us plan for the future or to remind us to do something important. Most of us are able to put our worries aside when we need to concentrate on other things or stop worrying altogether when the problem has passed. However, for someone with generalised anxiety disorder (GAD), these worries become difficult, if not impossible, to switch off. The person may find themselves worrying excessively about a number of different things, both minor and catastrophic. The DSM-5 criteria specify that, in order to receive a diagnosis of GWP, at least six months of excessive anxiety and worry of this kind must be continuous, occurring most days for a good part of the day. Around 5.7% of the population has met the criteria for GWP at some point in their lives (6), making it one of the most common anxiety disorders.
What makes a person with GWP worry more than the average person? Research shows that individuals with GWP are more sensitive and vigilant about possible threats than people who are not anxious (7). This may be related to early stressful experiences, which can lead to a view of the world as an unpredictable, uncontrollable and even dangerous place. Some have suggested that people with GWP worry as a way of gaining some control over these otherwise uncontrollable or unpredictable experiences and against uncertain outcomes (8). By repeatedly going through all the possible "What if?" scenarios in their mind, the person may feel that they are less vulnerable to an unexpected outcome, giving them the feeling that they have some control over the situation. Others have suggested that people with GWP worry as a way of avoiding feeling distressed (9). For example, it was found that those who worried constantly when faced with a stressful situation had less physiological stimulation than those who didn't worry, perhaps because worrying "distracted" them in some way.
The problem is that all this "what if?" doesn't bring the person any closer to a solution or answer and, in fact, can take them away from the important things they should be paying attention to at the moment, such as finishing an important project. Many of the catastrophic outcomes that people with GWP worry about are very unlikely to happen, so when the catastrophic event doesn't materialise, the act of worrying is reinforced (10). For example, if a mother spends all night worrying about whether her teenage daughter will get home safely after a night out and the daughter returns home without incident, the mother can easily attribute her daughter's safe return to the success of her "vigil". What the mother doesn't understand is that her daughter would have returned home just as safely if she had concentrated on the film she was watching with her husband, instead of worrying. In this way, the cycle of worry is perpetuated and, as a result, people with GWP often miss out on many pleasant events in their lives.
Panic disorder and agoraphobia
Have you ever had a near miss or been taken by surprise in some way? You may have felt an avalanche of physical sensations, such as a racing heart, shortness of breath or tingling sensations. This alarm reaction is called the "fight or flight" response (11) and is your body's natural reaction to fear, preparing you to fight or flee in response to a threat or danger. You probably weren't too worried about these sensations because you knew what was causing them. But imagine that this alarm reaction comes "out of the blue", for no apparent reason, or in a situation where you weren't expecting to be anxious or afraid. This is called an "unexpected" panic attack or a false alarm. As there is no apparent reason for the alarm reaction, you may react to the sensations with intense fear, perhaps thinking you are having a heart attack, going mad or even dying. You may begin to associate the physical sensations you felt during the attack with this fear, and you may start trying hard to avoid having those sensations again.
Unexpected panic attacks like these are at the centre of panic disorder (PD). However, to receive a diagnosis of PP, a person not only has to have unexpected panic attacks, they also have to experience intense and continuous anxiety for at least a month, causing significant distress or interference in their life. People with panic disorder tend to interpret even normal physical sensations in a catastrophic way, which triggers more anxiety and, ironically, more physical sensations, creating a vicious cycle of panic (12). The person may begin to avoid a series of situations or activities that produce the same physiological arousal that was present during the onset of a panic attack. For example, a person who has felt their heart racing during a panic attack might avoid exercise or caffeine. A person who has experienced feelings of suffocation might avoid wearing turtleneck jumpers. The avoidance of these internal bodily or somatic cues to panic is called interoceptive avoidance (13).
The individual may also have felt an irresistible urge to flee during the unexpected panic attack. This can lead to a feeling that certain places or situations - particularly situations in which escape may not be possible - are not "safe". These situations become external triggers for panic. If the person begins to avoid various places or situations, or even endures these situations but does so with a significant amount of apprehension and anxiety, then the person also has agoraphobia (1). Agoraphobia can cause significant disruption to a person's life, causing them to go out of their way to avoid situations, such as adding hours to a commute to avoid catching the train or only ordering food to avoid having to go into a grocery store. In one tragic case I dealt with, a woman suffering from agoraphobia hadn't left her flat for 20 years and had spent the last 10 years confined to a small area of her flat, out of sight of the outside. In some cases, agoraphobia develops in the absence of panic attacks, which is why it constitutes a separate disorder in the DSM-5. But agoraphobia often accompanies panic disorder.
Around 4.7% of the population has met the criteria for PP or agoraphobia in their lifetime (6). In all these cases of panic disorder, what was once a natural adaptive alarm reaction now becomes a learnt and much feared false alarm.
Specific phobias
Most of us can be afraid of certain things, like bees, needles or heights (14). But what if that fear is so intense that you can't go outside on a summer's day, or get the necessary vaccinations for a special trip, or visit the doctor in his new office on the 26th floor? To fulfil the criteria for a diagnosis of specific phobia, there has to be an irrational fear of a specific object or situation that substantially interferes with the person's ability to function. For example, one patient refused to move into a prestigious and coveted artist's residency because it required him to spend time near a wooded area where there were insects. Another patient purposely left the house two hours early every morning so that he could pass through his neighbour's fenced yard before he let his dog out in the morning.
The list of possible phobias is impressive, but four main subtypes of specific phobia are recognised: the blood-injury-injection type, the situational type (such as aeroplanes, lifts or enclosed spaces), the natural environment type for events that can be found in nature (for example, heights, storms and water) and the animal type.
A fifth category, "other", includes phobias that don't fit into any of the four main subtypes (for example, the fear of choking, vomiting or contracting a disease). Most phobic reactions cause a spike in activity in the sympathetic nervous system and an increase in heart rate and blood pressure, and a panic attack can even occur. However, people with needle or injection phobias usually experience a sharp drop in heart rate and blood pressure and may even faint. In this way, people with this type of phobia almost always differ in their physiological reaction from people with other types of phobia (15). This phobia is also more common in families than any other known phobic disorder. Most people who suffer from a specific phobia tend to have multiple phobias of various types (16).
Social anxiety disorder (social phobia)
Many people consider themselves shy, and most people find social evaluation uncomfortable at best, or giving a speech mortifying. However, only a small proportion of the population fears these types of situations significantly enough to merit a diagnosis of social anxiety disorder (SAD). SAD is more than exaggerated shyness (17). To receive a diagnosis of SAD, the fear and anxiety associated with social situations must be so strong that the person avoids them completely or, if it is not possible to avoid them, endures them with great distress. In addition, the fear and avoidance of social situations must interfere with the person's daily life or seriously limit their academic or professional functioning. For example, one patient jeopardised her perfect GPA because she couldn't complete an oral presentation required in one of her classes, which led her to fail the subject. Fear of a negative evaluation can cause someone to repeatedly turn down invitations to social events or avoid talking to people, leading to increasing isolation.
The specific social situations that trigger anxiety and fear range from one-to-one interactions, such as starting or maintaining a conversation; to performance-based situations, such as giving a speech or performing on stage; to assertiveness, such as asking someone to change disturbing or undesirable behaviour. Fear of social evaluation can even extend to situations such as using public toilets, eating in a restaurant, filling in forms in a public place or even reading on a train. Any kind of situation that could potentially draw attention to the person can become a feared social situation. For example, one patient went out of her way to avoid any situation in which she had to use a public toilet, for fear that someone would hear her in the loo and think she was disgusting. If the fear is limited to performance-based situations, such as public speaking, a diagnosis of performance-only GWP is given.
What makes someone so afraid of social situations? The person may have learnt while growing up that social evaluation in particular can be dangerous, creating a specific psychological vulnerability to develop social anxiety (18). For example, the person's parents may have criticised and punished them harshly for even the slightest mistake, perhaps even physically punishing them.
Or someone may have suffered a social trauma that had lasting effects, such as being bullied or humiliated. Interestingly, a group of researchers found that 92% of the adults in their study sample with social phobia had suffered severe teasing and bullying in childhood, compared to only 35% to 50% of people with other anxiety disorders (19). Another person can react so strongly to the anxiety caused by a social situation that they have an unexpected panic attack. This panic attack then becomes associated (conditioned response) with the social situation, making the person afraid of panicking the next time they are in that situation. However, this is not considered PP, because the person's fear is more centred on social evaluation than on having unexpected panic attacks, and the fear of having an attack is limited to social situations. Around 12.1% of the general population suffer from social phobia at some point in their lives (6), making it one of the most common anxiety disorders, second only to specific phobia.
Post-traumatic stress disorder
With stories of war, natural disasters and physical and sexual assault dominating the news, it's clear that trauma is a reality for many people. Many individual traumas that occur every day don't even make the headlines, such as a road accident, domestic violence or the death of a loved one. However, although many people face traumatic events, not everyone who faces a trauma develops a disorder. Some, with the help of family and friends, manage to recover and get on with their lives. For some, however, the months and years following a trauma are filled with intrusive memories of the event, a sense of intense fear that another traumatic event may occur, or a feeling of isolation and emotional numbness. They may adopt a series of behaviours to protect themselves from situations of vulnerability or insecurity, such as constantly scanning their surroundings for signs of potential danger, never sitting with their back to the door or never allowing themselves to be alone anywhere. This lasting reaction to trauma is what characterises post-traumatic stress disorder (PTSD).
The diagnosis of PTSD begins with the traumatic event itself. An individual must have been exposed to an event involving actual or threatened death, serious injury or sexual violence. In order to receive a diagnosis of PTSD, exposure to the event must include direct experience of the event, witnessing the occurrence of the event to another person, knowledge that the event occurred to a close family member or friend, or repeated or extreme exposure to details of the event (as in the case of first responders and other professionals working in and with extreme situations). Subsequently, the person relives the event through intrusive memories and nightmares. Some memories can be so vivid that the person feels they are living the event all over again, which is known as a flashback. The individual may avoid anything that reminds them of the trauma, including conversations, places or even specific types of people. They may feel emotionally numb or limited in their ability to feel, which can interfere with their interpersonal relationships. The person may not be able to remember certain aspects of what happened during the event. The person may have the feeling that their future is being cut short, that they will never marry, have a family or live a long and full life. They may feel nervous or frightened easily, hypervigilant about their surroundings and have fits of rage.
The prevalence of PTSD in the general population is relatively low, with 6.8% of people having suffered PTSD at some point in their lives (6). Combat and sexual assault are the most common precipitating traumas (6). While PTSD was previously categorised as an Anxiety Disorder, in the most recent version of the DSM it was reclassified under the more specific category of Trauma- and Stressor-Related Disorders.
A person with PTSD is particularly sensitive to internal and external signals that serve as a reminder of their traumatic experience. For example, as we saw in PP, the extreme physical sensations present during the initial trauma can become threatening in themselves, becoming a powerful reminder of the event. A person may avoid watching intense or emotional films to avoid the extreme emotional experience. Avoiding conversations, memories or even the experience of the emotion itself can also be an attempt to avoid triggering internal signals. External stimuli that were present during the trauma can also become strong triggers. For example, if a woman is raped by a man wearing a red T-shirt, she may develop a strong alarm reaction to the sight of red shirts, or perhaps even more indiscriminately to anything with a similar red colour. A combat veteran who smelled a strong petrol smell during a roadside bomb attack may have an intense alarm reaction when filling up with petrol at home. Individuals with a psychological vulnerability to seeing the world as uncontrollable and unpredictable may particularly struggle with the possibility of additional, unpredictable future traumatic events, fuelling their need for hypervigilance and avoidance and perpetuating PTSD symptoms.
Obsessive-Compulsive Disorder
Have you ever had a strange thought cross your mind, like imagining the stranger next to you naked? Or maybe you've walked past a crooked picture on the wall and couldn't resist straightening it out. Most people occasionally have strange thoughts and may even engage in some "compulsive" behaviour, especially when they're stressed (20). But for most people, these thoughts are just a passing oddity and the behaviours are done (or not done) without a second thought. For someone with obsessive-compulsive disorder (OCD), however, these compulsive thoughts and behaviours don't come and go. Instead, the strange or unusual thoughts are interpreted as meaning something much more important and real, perhaps even something dangerous or frightening. The desire to adopt a certain behaviour, such as straightening a picture, can become so intense that it's almost impossible not to do it, or cause significant anxiety if it can't be carried out. In addition, a person with OCD may worry that the behaviour has not been carried out to completion and feel compelled to repeat the behaviour over and over again, perhaps several times until they are "satisfied".
To receive a diagnosis of OCD, a person has to have obsessive thoughts and/or compulsions that seem irrational or meaningless, but which keep popping up in their mind. Some examples of obsessions include thoughts of doubt (such as doubting that a door is locked or that an appliance is switched off), thoughts of contamination (such as thinking that touching almost anything can cause cancer), or aggressive thoughts or images that are unprovoked or make no sense. Compulsions can be carried out in an attempt to neutralise some of these thoughts, providing temporary relief from the anxiety that obsessions cause, or they can be absurd in themselves. In any case, compulsions are distinguished by the fact that they are repetitive or excessive, that the person feels "driven" to carry out the behaviour and that they feel great anguish if they fail to carry out the behaviour. Some examples of compulsive behaviours are repetitive washing (often in response to contamination obsessions), repetitive checking (locks, doorknobs, household appliances, often in response to doubt obsessions), sorting and organising things to ensure symmetry, or doing things according to a specific ritual or sequence (such as getting dressed or getting ready for bed in a specific order).
To fulfil the diagnostic criteria for OCD, involvement in obsessions and/or compulsions must occupy a significant amount of the person's time, at least one hour a day, and must cause significant suffering or impairment in functioning. Around 1.6% of the population fulfil the criteria for lifetime OCD (6). While OCD was previously classified as an Anxiety Disorder, in the most recent version of the DSM it was reclassified under the more specific category of Obsessive-Compulsive and Related Disorders.
People with OCD often confuse the fact that they have an intrusive thought with the possibility of realising it. While most people, when they have a strange or frightening thought, are able to let it go, a person with OCD can get "stuck" in the thought and have an intense fear that they might somehow lose control and act on it. Or worse, they believe that having the thought is just as bad as acting on it. This is called thought-action fusion. For example, a patient of mine was tormented by thoughts that she was going to harm her young daughter. She had intrusive images of throwing hot coffee in her daughter's face or putting her face under water when she was bathing her. These images were so terrifying for the patient that she no longer allowed herself any physical contact with her daughter and would leave her in the care of a babysitter if her husband or other family wasn't available to "supervise" her. In reality, the last thing she wanted to do was hurt her daughter, and she had no intention or desire to act on the aggressive thoughts and images, nor does anyone with OCD act on such thoughts, but these thoughts were so horrible to her that she made every attempt to prevent the possibility of realising them, even if it meant not being able to hold her daughter, rock her or cuddle her. These are the kinds of struggles that people with OCD face every day.
Treatments for anxiety and related disorders
Over the years, many successful treatments have been developed for anxiety and related disorders. Medications (anxiolytics and antidepressants) have proven beneficial for disorders other than specific phobia, but relapse rates are high when medications are discontinued (21), and some classes of medication (minor tranquillisers or benzodiazepines) can be habit-forming.
Exposure-based cognitive-behavioural therapies (CBT) are effective psychosocial treatments for anxiety disorders, and many show superior treatment effects over long-term medication (22). In CBT, patients learn skills to help identify and change problematic thought processes, beliefs and behaviours that tend to aggravate anxiety symptoms, and practice applying these skills to real-life situations through exposure exercises. Patients learn how the "evaluations" or automatic thoughts they have about a situation affect both the way they feel and the way they behave. Similarly, patients learn how adopting certain behaviours, such as avoiding situations, tends to reinforce the belief that the situation is something to be feared. A key aspect of CBT is exposure exercises, in which the patient learns to gradually approach situations that they find fearful or distressing, in order to challenge their beliefs and learn new, less fearful associations about those situations.
Typically, 50% to 80% of patients receiving medication or CBT show a good initial response, with the effect of CBT being longer lasting. Recent developments in the treatment of anxiety disorders are focusing on new interventions, such as the use of certain medications to enhance learning during CBT (Otto et al., 2010) and transdiagnostic treatments that target fundamental and underlying vulnerabilities (Barlow et al., 2011). As we advance in our understanding of anxiety and related disorders, so do our treatments, with the hope that for the many people who suffer from these disorders, anxiety can once again become something useful and adaptive, rather than something debilitating.
References:
(3) Genetic variation in 5HTTLPR is associated with emotional resilience - PubMed (nih.gov)
(7) Cognitive theories of generalised anxiety disorder - PubMed (nih.gov)
(11) ORGANISATION FOR PHYSIOLOGICAL HOMEOSTASIS | Physiological Reviews (physiology.org)
(12) A cognitive approach to panic - ScienceDirect
(13) A psychometric reanalysis of the Albany Panic and Phobia Questionnaire - PubMed (nih.gov)
(14) Gender differences in phobias: Results of the ECA community survey - ScienceDirect
(15) Phenomenology of Panic and Phobic Disorders | Request PDF (researchgate.net)
(16) How specific are specific phobias? - PubMed (nih.gov)
(17) Social anxiety and social norms in individualistic and collectivistic countries - PubMed (nih.gov)
(20) (PDF) Whence Cultural Rituals? A Cultural Selection Model of Ritualised Behavior (researchgate.net)
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