Anxiety Disorders

Symptoms of Anxiety Disorders

Mark Dombeck, Ph.D.

Worried you may be suffering from a panic attack, agoraphobia or some other type of anxiety disorder? Check here for the symptoms you should look for before consulting a mental health professional.

Panic Disorder

People with panic disorder have feelings of terror that strike suddenly and repeatedly with no warning. They can't predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike. In between times there is a persistent, lingering worry that another attack could come any minute.

When a panic attack strikes, most likely your heart pounds and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. You may genuinely believe you're having a heart attack or stroke, losing your mind, or on the verge of death. Attacks can occur any time, even during non-dream sleep. While most attacks average a couple of minutes, occasionally they can go on for up to 10 minutes. In rare cases, they may last an hour or more.

 

Panic disorder strikes between 3 and 6 million Americans, and is twice as common in women as in men. It can appear at any age--in children or in the elderly--but most often it begins in young adults. Not everyone who experiences panic attacks will develop panic disorder-- for example, many people have one attack but never have another. For those who do have panic disorder, though, it's important to seek treatment. Untreated, the disorder can become very disabling.

Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may spawn phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding an elevator, you may develop a fear of elevators and perhaps start avoiding them.

Some people's lives become greatly restricted -- they avoid normal, everyday activities such as grocery shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, they avoid any situation they fear would make them feel helpless if a panic attack occurs. When people's lives become so restricted by the disorder, as happens in about one-third of all people with panic disorder, the condition is called agoraphobia. A tendency toward panic disorder and agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop the progression to agoraphobia.

Specific Symptoms of Panic Disorder:

The person experiences recurrent unexpected Panic Attacks. A panic attack is a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

 

  • palpitations, pounding heart, or accelerated heart 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 flushes

and at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

  • persistent concern about having additional attacks
  • worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
  • a significant change in behavior related to the attacks

Agoraphobia (see below) may be present.

The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995).

Agoraphobia

Agoraphobia invoves 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 having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

The feared situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

Most of the time, panic attacks co-occur with this disorder; It is fairly rare for agoraphobia to be diagnosed without them.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995)

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. It's chronic and exaggerated worry and tension, even though nothing seems to provoke it. Having this disorder means always anticipating disaster, often worrying excessively about health, money, family, or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day provokes anxiety.

People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. People with GAD also seem unable to relax. They often have trouble falling or staying asleep. Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating, and sometimes suffer depression, too.

Usually the impairment associated with GAD is mild and people with the disorder don't feel too restricted in social settings or on the job. Unlike many other anxiety disorders, people with GAD don't characteristically avoid certain situations as a result of their disorder. However, if severe, GAD can be very debilitating because of the excessive worrying, making it difficult to carry out even the most ordinary daily activities.

GAD comes on gradually and most often hits people in childhood or adolescence, but can begin in adulthood, too. It's more common in women than in men and often occurs in relatives of affected persons. It's diagnosed when someone spends at least 6 months worried excessively about a number of everyday problems.

Specific Symptoms of GAD:

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

The person finds it difficult to control the worry.

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months; children don't need to meet as many criteria).

  • restlessness or feeling keyed up or on edge
  • being easily fatigued
  • difficulty concentrating or mind going blank
  • irritability
  • muscle tension
  • sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Additionally, the anxiety or worry is not about having a Panic Attack, being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder (PTSD).

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995).

Obsessive-Compulsive Disorder

Please visit our separate Obsessive-Compulsive Disorder Center to learn the symptoms of this anxiety disorder.

Acute Stress Disorder

The person has been exposed to a traumatic event in which both of the following were present:

  • the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
  • the person's response involved intense fear, helplessness, or horror

Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

  • a subjective sense of numbing, detachment, or absence of emotional responsiveness
  • a reduction in awareness of his or her surroundings (e.g., "being in a daze")
  • derealization
  • depersonalization
  • dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

The person experiences marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

The person experiences marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting mental disorder.

Criteria summarized from:American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. War veterans first brought PTSD, once referred to as shell shock or battle fatigue, to public attention, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.

Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult.

PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if a person--such as a rape, as opposed to a flood, initiated the event that triggered them.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.

Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.

Specific Symptoms of PTSD:

The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. Note: In children this may be manifested by irritable or disorganized behavior.

The traumatic event is persistently re-experienced in one (or more) of the following ways:

  • recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
  • recurrent distressing dreams of the event.
  • acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
  • intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  • physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

  • efforts to avoid thoughts, feelings, or conversations associated with the trauma
  • efforts to avoid activities, places, or people that arouse recollections of the trauma
  • inability to recall an important aspect of the trauma
  • markedly diminished interest or participation in significant activities
  • feeling of detachment or estrangement from others
  • restricted range of affect (e.g., unable to have loving feelings)
  • sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

  • difficulty falling or staying asleep
  • irritability or outbursts of anger
  • difficulty concentrating
  • hypervigilance
  • exaggerated startle response

The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995)

Social Phobia

Social phobia is an intense fear of possible scrutiny by others in a social situation. The individual experiences a great deal of fear about becoming humiliated in social situations, specifically of embarrassing yourself in front of other people. It often runs in families and may be accompanied by depression or alcoholism. Social phobia often begins around early adolescence or even younger. If you suffer from social phobia, you tend to think that other people are very competent in public and that you are not. Small mistakes you make may seem to you much more exaggerated than they really are. Blushing itself may seem painfully embarrassing, and you feel as though all eyes are focused on you. You may be afraid of being with people other than those closest to you. Or your fear may be more specific, such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating. The most common social phobia is a fear of public speaking. Sometimes social phobia involves a general fear of social situations such as parties. More rarely it may involve a fear of using a public restroom, eating out, talking on the phone, or writing in the presence of other people, such as when signing a check. Although this disorder is often thought of as shyness, the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious. In contrast, people with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating. People with social phobia are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and they may go out of their way to avoid it. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterwards, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

Specific Symptoms of Social Phobia:

A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.

The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

In individuals under age 18 years, the duration is at least 6 months.

The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.

If a general medical condition or another mental disorder is present, the fear in the first criteria is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995)

Specific Phobia

Many people experience specific phobias; intense, irrational fears of certain things or situations--dogs, closed-in places, heights, escalators, tunnels, highway driving, water, flying, and injuries involving blood are a few of the more common ones. Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountains with ease, but then panic going above the 10th floor of an office building. Adults with phobias realize their fears are irrational, but often facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias strike more than 1 in 10 people. No one knows just what causes them, although they seem to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood. They start suddenly and tend to be more persistent than childhood phobias; only about 20 percent of adult phobias vanish on their own. When children have specific phobias--for example, a fear of animals--those fears usually disappear over time, though they may continue into adulthood. No one knows why they hang on in some people and disappear in others.

Specific Symptoms of Specific Phobias:

Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.

The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.

The phobic situation(s) is avoided or else is endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

In individuals under age 18 years, the duration is at least 6 months.

The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder.

References:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3879 (1995).

 




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