- Clinical science
Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent fear (an emotional response to imminent threats), anxiety (the anticipation of a future threat), worry (apprehensive expectation), and/or avoidance behavior. The etiology of anxiety disorders is multifactorial and may involve genetic, developmental, environmental, neurobiological, cognitive, and psychosocial factors. Therapy typically consists of a combination of pharmacotherapy, especially selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, especially cognitive-behavioral therapy (CBT).
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|Generalized anxiety disorder (GAD)||Panic disorder||Social anxiety disorder (SAD)||Specific phobias||Agoraphobia||Substance/medication-induced anxiety disorder|
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|Triggers|| || || || || |
|Duration of symptoms required for diagnosis|| || || || || || |
Risk and prognostic factors
- Higher rates of anxiety disorders are reported in women.
- Neurobiological factors
- Disruption of the serotonin system
- Dysfunction of GABAergic inhibitory transmission
- Substance use (leading to substance/medication-induced anxiety disorder)
- Environmental and developmental factors
- Other medical conditions
- Definition: prolonged and excessive anxiety that is either unspecific or revolves around certain themes (e.g., health, work); not focused on a single specific fear
- Most common anxiety disorder among the elderly population
- Lifetime prevalence: 5–10%
- ♀ > ♂(2:1)
- Prolonged (≥ 6 months, occurring more days than not) and excessive anxiety
- Anxiety causes clinically significant distress
- Not caused by substance use, medication, or underlying medical condition
- Fatigue and muscle tension
- Restlessness and irritability
- Sleep disturbances and difficulty concentrating
- First-line: psychotherapy, pharmacotherapy, or both
Panic disorder: Panic attacks may also occur in GAD.
- Panic symptoms in GAD are generally precipitated by the uncontrolled escalation of anxiety/worry rather than occurring spontaneously or acutely in specific situations as in panic disorder.
- Depressive disorders
- SAD: Patients with GAD are usually comfortable in social situations and not particularly disturbed by the evaluation by others.
- Panic disorder: Panic attacks may also occur in GAD.
- Definition: recurrent spontaneous and unexpected panic attacks that often occur without a known trigger
- Lifetime prevalence: approx. 5% of the population
- Most common in patients aged 26–34 years
- ♀ > ♂ (2:1)
- Recurrent panic attacks
- There is a concern about future attacks and their consequences, and/or a significant change in behavior related to the attacks, for at least one month.
To remember the symptoms of a panic attack, think of “STUDENTS FEAR the 3Cs”: Sweating, Trembling, Unsteadiness (dizziness), Derealization, Elevated heart rate (palpitations), Nausea, Tingling, and Shortness of breath; FEAR of dying or going crazy; Chest pain, Choking, and Chills.
- Definition: pronounced anxiety lasting ≥ 6 months of social situations that might involve scrutiny by others
- Social anxiety disorder (SAD): fear/anxiety out of proportion to a social situation where one may be scrutinized by others (e.g., meeting new people at a party, eating in public, using public restrooms)
- Performance-only SAD: symptoms of fear/anxiety restricted only to public speaking or performing in front of crowds
- Blushing, palpitations, sweating during a social interaction
- Anticipatory anxiety (e.g., worrying weeks in advance about attending a social event)
- Anxiety driven by fear of embarrassment and others noticing the reaction
- Avoidance of the aforementioned triggers (e.g., not attending parties, refusing to attend school)
- In children: refusing to speak at social events, crying/throwing a tantrum, clinging to their caregiver
- CBT for SAD and performance-only SAD
- Pharmacotherapy for SAD
- Pharmacotherapy for performance-only SAD: (beta-blockers) or on an as-needed basis; taken 30–60 minutes before an anxiety-causing event
- Definition: persistent and intense fears of one or more specific situations or objects (phobic stimuli); always occurs during encounters with the phobic stimulus but may already surge in anticipation of an encounter
- Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
- Natural environment: heights (acrophobia), storms (astraphobia)
- Blood-injection-injury: blood (), needles (blenophobia), dental procedures (odontophobia), fear of injury (traumatophobia)
- Situational: enclosed places (claustrophobia), flying (aviophobia)
- Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia), costumed characters (masklophobia), fear of clowns (coulrophobia)
- Definition: pronounced fear or anxiety of being in situations that are perceived as difficult to escape from or situations in which it might be difficult to seek help
- ♀ > ♂ (2:1)
- Age of onset: < 35 years (60–70% of cases)
Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 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
- Active avoidance of these settings unless a companion is present
- Some patients can have comorbid panic disorder.
- Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
- Definition: prominent anxiety or panic attacks within 1 month of use of, or withdrawal from, a substance/medication that is capable of inducing anxiety symptoms 
- Causes 
- Clinical features