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Overview of Anxiety Disorders

By John H. Greist, MD

Anxiety disorders involve a state of distressing chronic but fluctuating nervousness that is inappropriately severe for the person's circumstances.

  • Anxiety disorders can make people sweat, feel short of breath or dizzy, have a rapid heartbeat, tremble, and avoid certain situations.

  • These disorders are usually diagnosed using specific established criteria.

  • Drugs, psychotherapy, or both can substantially help most people.

Anxiety is a normal response to a threat or to psychologic stress and is experienced occasionally by everyone. Normal anxiety has its root in fear and serves an important survival function. When someone is faced with a dangerous situation, anxiety triggers the fight-or-flight response. With this response, a variety of physical changes, such as increased blood flow to the heart and muscles, provide the body with the necessary energy and strength to deal with life-threatening situations, such as running from an aggressive animal or fighting off an attacker. However, when anxiety occurs at inappropriate times, occurs frequently, or is so intense and long-lasting that it interferes with a person's normal activities, it is considered a disorder.

Anxiety disorders are more common than any other category of mental health disorder and are believed to affect about 15% of adults in the United States. However, anxiety disorders often are not recognized by people who have them or by health care practitioners and consequently are seldom treated.

Anxiety disorders include

The mental distress that occurs immediately or shortly after experiencing or witnessing an overwhelming traumatic event is no longer classified as an anxiety disorder. Such disorders are now classified as trauma- and stress-related disorders and include acute stress disorder and posttraumatic stress disorder (PTSD).

How Anxiety Affects Performance

The effects of anxiety on performance can be shown on a curve. As the level of anxiety increases, performance efficiency increases proportionately, but only up to a point. As anxiety increases further, performance efficiency decreases. Before the peak of the curve, anxiety is considered adaptive because it helps people prepare for a crisis and improve their functioning. Beyond the peak of the curve, anxiety is considered maladaptive because it produces distress and impairs functioning.

Causes

The causes of anxiety disorders are not fully known, but the following may be involved:

  • Genetic factors (including a family history)

  • Environment (such as experiencing a traumatic event or stress)

  • Psychologic make-up

  • A physical condition

An anxiety disorder can be triggered by environmental stresses, such as the breakup of a significant relationship or exposure to a life-threatening disaster.

When a person's response to stresses is inappropriate or a person is overwhelmed by events, an anxiety disorder can arise. For example, some people find speaking before a group exhilarating. But others dread it, becoming anxious with symptoms such as sweating, fear, a rapid heart rate, and tremor. Such people may avoid speaking even in a small group.

Anxiety tends to run in families. Doctors think some of this tendency may be inherited, but some is probably learned by living with anxious people.

Did You Know...

  • Anxiety disorders are the most common type of mental health disorder.

  • People with an anxiety disorder are more likely than other people to have depression.

Anxiety caused by a physical disorder or drug

Anxiety can also be caused by a physical disorder or the use or discontinuation (withdrawal) of a drug. Physical disorders that can cause anxiety include the following:

  • Heart disorders, such as heart failure and abnormal heart rhythms (arrhythmias)

  • Hormonal (endocrine) disorders, such as an overactive adrenal gland (hyperadrenocorticism) or thyroid gland (hyperthyroidism) or a hormone-secreting tumor called a pheochromocytoma

  • Lung (respiratory) disorders, such as asthma and chronic obstructive pulmonary disease (COPD)

Even fever can cause anxiety.

Anxiety may occur in dying people as a result of fear of death, pain, and difficulty breathing (see Symptoms During a Fatal Illness : Depression and Anxiety).

Drugs that can trigger anxiety include the following:

  • Alcohol

  • Stimulants (such as amphetamines)

  • Caffeine

  • Cocaine

  • Many prescription drugs, such as corticosteroids

  • Some over-the-counter weight-loss products, such as those containing the herbal product guarana, caffeine, or both

Withdrawal from alcohol or sedatives, such as benzodiazepines (used to treat anxiety disorders), can cause anxiety and other symptoms, such as insomnia and restlessness.

Symptoms

Anxiety can arise suddenly, as in panic, or gradually over minutes, hours, or days. Anxiety can last for any length of time, from a few seconds to years. It ranges in intensity from barely noticeable qualms to a full-blown panic attack, which may cause shortness of breath, dizziness, an increased heart rate, and trembling (tremor).

Anxiety disorders can be so distressing and interfere so much with a person's life that they can lead to depression. People who have an anxiety disorder (except for certain very specific phobias, such as fear of spiders) are at least twice as likely to have depression as those without an anxiety disorder. Sometimes people with depression develop an anxiety disorder.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Deciding when anxiety is severe enough to be considered a disorder can be complicated. People's ability to tolerate anxiety varies, and determining what constitutes abnormal anxiety can be difficult. Doctors usually use the following specific established criteria:

  • Anxiety is very distressing.

  • Anxiety interferes with functioning.

  • Anxiety does not stop on its own within a few days.

Doctors ask whether family members have had similar symptoms. A family history of an anxiety disorder (except posttraumatic stress disorder, which results from a specific event) may help doctors make the diagnosis.

Doctors also do a physical examination. Blood and other tests may be done to check for physical disorders that can cause anxiety.

Treatment

  • Treatment of the cause if appropriate

  • Psychotherapy

  • Drug therapy

Accurate diagnosis is important because treatment varies from one anxiety disorder to another. Additionally, anxiety disorders must be distinguished from anxiety that occurs in many other mental health disorders, which involve different treatment approaches.

If the cause is a physical disorder or a drug, doctors aim to correct the cause rather than treat the symptoms of anxiety. Anxiety should subside after the physical disorder is treated or the drug has been stopped long enough for any withdrawal symptoms to abate. If anxiety remains, antianxiety drugs or psychotherapy (such as behavioral therapy) is used.

For people who are dying, strong pain relievers (analgesics) with potent antianxiety effects, such as morphine, are often appropriate. No dying person should have to experience intense anxiety.

If an anxiety disorder is diagnosed, drug therapy or psychotherapy (such as behavioral therapy), alone or in combination, can significantly relieve the distress and dysfunction for most people. Specific treatments depend on which anxiety disorder is diagnosed.

Drugs Used to Treat Anxiety Disorders

Drug

Uses

Some Side Effects

Comments

Benzodiazepines

Alprazolam

Chlordiazepoxide

Clonazepam

Clorazepate

Diazepam

Lorazepam

Oxazepam

Generalized anxiety disorder

Panic disorder

Phobic disorders

Sleepiness, memory problems, impaired coordination, and slowed reaction time

May lead to drug dependence

Most commonly used type of antianxiety drug

Promote mental and physical relaxation by reducing nerve activity in the brain

Begin to work quickly, sometimes within an hour

Should not be used by people who are dependent on alcohol

Buspirone

Generalized anxiety disorder

Dizziness and headache

Does not cause drowsiness or interact with alcohol

Does not lead to drug dependence

May take several weeks to start working

Antidepressants*

Selective serotonin reuptake inhibitors (such as escitalopram)

Serotonin- norepinephrine reuptake inhibitors (such as venlafaxine)

Monoamine oxidase inhibitors

Tricyclic antidepressants (such as clomipramine)

Generalized anxiety disorder

Panic disorder

Phobic disorders

Posttraumatic stress disorder

*Not all of the antidepressants listed work for all of the uses that are listed.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • No US brand name
  • LEVOPHED
  • EFFEXOR XR
  • VALIUM
  • DURAMORPH PF, MS CONTIN
  • LEXAPRO
  • TRANXENE
  • XANAX
  • ANAFRANIL
  • ATIVAN
  • LIBRIUM
  • KLONOPIN