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Understanding Anxiety Disorders by NIH

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Understanding Anxiety Disorders
When Panic, Fear, and Worries Overwhelm
Illustration of a worried man standing apart from a circle of friends.

Many of us worry from time to time. We fret over finances, feel anxious about job interviews, or get nervous about social gatherings. These feelings can be normal or even helpful. They may give us a boost of energy or help us focus. But for people with anxiety disorders, they can be overwhelming.

Anxiety disorders affect nearly 1 in 5 American adults each year. People with these disorders have feelings of fear and uncertainty that interfere with everyday activities and last for 6 months or more. Anxiety disorders can also raise your risk for other medical problems such as heart disease, diabetes, substance abuse, and depression.

The good news is that most anxiety disorders get better with therapy. The course of treatment depends on the type of anxiety disorder. Medications, psychotherapy (“talk therapy”), or a combination of both can usually relieve troubling symptoms.

“Anxiety disorders are one of the most treatable mental health problems we see,” says Dr. Daniel Pine, an NIH neuroscientist and psychiatrist. “Still, for reasons we don’t fully understand, most people who have these problems don’t get the treatments that could really help them.”

One of the most common types of anxiety disorder is social anxiety disorder, or social phobia. It affects both women and men equally—a total of about 15 million U.S. adults. Without treatment, social phobia can last for years or even a lifetime. People with social phobia may worry for days or weeks before a social event. They’re often embarrassed, self-conscious, and afraid of being judged. They find it hard to talk to others. They may blush, sweat, tremble, or feel sick to their stomach when around other people.

Other common types of anxiety disorders include generalized anxiety disorder, which affects nearly 7 million American adults, and panic disorder, which affects about 6 million. Both are twice as common in women as in men.

People with generalized anxiety disorder worry endlessly over everyday issues—like health, money, or family problems—even if they realize there’s little cause for concern. They startle easily, can’t relax, and can’t concentrate. They find it hard to fall asleep or stay asleep. They may get headaches, muscle aches, or unexplained pains. Symptoms often get worse during times of stress.

People with panic disorder have sudden, repeated bouts of fear—called panic attacks—that last several minutes or more. During a panic attack, they may feel that they can’t breathe or that they’re having a heart attack. They may fear loss of control or feel a sense of unreality. Not everyone who has panic attacks will develop panic disorder. But if the attacks recur without warning, creating fear of having another attack at any time, then it’s likely panic disorder.

Anxiety disorders tend to run in families. But researchers aren’t certain why some family members develop these conditions while others don’t. No specific genes have been found to actually cause an anxiety disorder. “Many different factors—including genes, stress, and the environment—have small effects that add up in complex ways to affect a person’s risk for these disorders,” Pine says.

“Many kids with anxiety disorders will outgrow their conditions. But most anxiety problems we see in adults started during their childhood,” Pine adds.

“Anxiety disorders are among the most common psychiatric disorders in children, with an estimated 1 in 3 suffering anxiety at some point during childhood or adolescence,” says Dr. Susan Whitfield-Gabrieli, a brain imaging expert at the Massachusetts Institute of Technology. “About half of diagnosable mental health disorders start by age 14, so there’s a lot of interest in uncovering the factors that might influence the brain by those early teen years.”

Whitfield-Gabrieli is launching an NIH-funded study to create detailed MRI images of the brains of more than 200 teens, ages 14-15, with and without anxiety or depression. The scientists will then assess what brain structures and activities might be linked to these conditions. The study is part of NIH’s Human Connectome Project, in which research teams across the country are studying the complex brain connections that affect health and disease.

Whitfield-Gabrieli and colleagues have shown that analysis of brain connections might help predict which adults with social phobia will likely respond to cognitive behavioral therapy (CBT). CBT is a type of talk therapy known to be effective for people with anxiety disorders. It helps them change their thinking patterns and how they react to anxiety-provoking situations. But it doesn’t work for everyone.

Of 38 adults with social phobia, those who responded best after 3 months of CBT had similar patterns of brain connections. This brain analysis led to major improvement, compared to a clinician’s assessment alone, in predicting treatment response. Larger studies will be needed to confirm the benefits of the approach.

“Ultimately, we hope that brain imaging will help us predict clinical outcomes and actually tailor the treatment to each individual—to know whether they’ll respond best to psychotherapy or to certain medications,” Whitfield-Gabrieli says.

Other researchers are focusing on our emotions and our ability to adjust them. “We want to understand not only how emotions can help us but also how they can create difficulties if they’re of the wrong intensity or the wrong type for a particular situation,” says Dr. James Gross, a clinical psychologist at Stanford University.

We all use different strategies to adjust our emotions, often without thinking about it. If something makes you angry, you may try to tamp down your emotion to avoid making a scene. If something annoys you, you might try to ignore it, modify it, or entirely avoid it.

But these strategies can turn harmful over time. For instance, people with social phobia might decide to avoid attending a professional conference so they can keep their anxiety in check. That makes them lose opportunities at work and miss chances to meet people and make friends.

Gross and others are examining the differences between how people with and without anxiety disorders regulate their emotions. “We’re finding that CBT is helpful in part because it teaches people to more effectively use emotion regulation strategies,” Gross says. “They then become more competent in their ability to use these strategies in their everyday lives.”

“It’s important to be aware that many different kinds of treatments are available, and people with anxiety disorders tend to have very good responses to those treatments,” Pine adds. The best way to start is often by talking with your physician. If you’re a parent, talk with your child’s pediatrician. “These health professionals are generally prepared to help identify such problems and help patients get the appropriate care they need,” Pine says.


The role of emotion and emotion regulation in social anxiety disorder. Jazaieri H, Morrison AS, Goldin PR, Gross JJ. Curr Psychiatry Rep. 2015 Jan;17(1):531. doi: 10.1007/s11920-014-0531-3. Review. PMID: 25413637.

Childhood antecedents and risk for adult mental disorders. Pine DS, Fox NA. Annu Rev Psychol. 2015 Jan 3;66:459-85. doi: 10.1146/annurev-psych-010814-015038. Review. PMID: 25559116.

Brain connectomics predict response to treatment in social anxiety disorder. Whitfield-Gabrieli S, Ghosh SS, Nieto-Castanon A, et al. Mol Psychiatry. 2015 Aug 11. doi: 10.1038/mp.2015.109. [Epub ahead of print]. PMID: 26260

Troubled by Anxiety?

If feelings of anxiety seem overwhelming or interfere with every-day activities:

See your family doctor or nurse practitioner.
The next step may be talking to a mental health professional. Consider finding someone trained in cognitive-behavioral therapy who is also open to using medication if needed. You may need to try several medicines before finding the right one.
Consider joining a self-help or support group to share problems and achievements with others.
Stress management techniques and mindfulness meditation may help relieve anxiety symptoms.

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Anxiety Disorders.

Frequently Asked Questions about Anxiety Disorders

What are the five types of anxiety disorders that are well known?

  1. Generalized Anxiety Disorder
  2. Obsessive-Compulsive Disorder (OCD)
  3. Panic Disorder
  4. Post-Traumatic Stress Disorder (PTSD)
  5. Social Phobia (or Social Anxiety Disorder)

What is generalized anxiety disorder?
Generalized Anxiety Disorder (GAD) is an exaggerated anxiety and tension that persists for months on end and affects approximately 6.8 million Americans or about 3.1 percent of the population. GAD causes people to anticipate catastrophe and worry excessively about many things, from overarching concerns such as health, money or work to more routine concerns such as car repairs or appointments. GAD affects twice as many women as men, and the anxiety becomes so severe, normal life and relationships become impaired.

Worries can be accompanied by physical symptoms, such as fatigue, headaches, muscle tension and aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes. The disorder usually develops gradually and may begin anytime during life, although the risk is highest between childhood and middle age. It is diagnosed when someone spends at least six months worrying excessively without a specific focus of the fear and an inability to control the anxiety.

What is Obsessive-Compulsive Disorder?
Obsessive-Compulsive Disorder (OCD) is an anxiety disorder marked by fearful ideas and ritualistic behaviors. Obsessions are repetitive thoughts or impulses, such as a fear of getting infected from someone else’s germs or hurting a loved one. These obsessions create excessive anxiety and stress for the person affected. Although the thoughts are intrusive and unwanted, the person with OCD cannot stop them. Compulsions are repetitive behaviors people with OCD feel compelled to perform in an attempt to control or decrease the anxiety created by the obsessions. This can include things like constantly checking that an oven is off to prevent a fire, or frequent cleaning or hand-washing to avoid contamination.

What is Panic Disorder?
Panic disorder is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness or abdominal distress. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom or a fear of losing control. Panic attacks can occur at any time, even during sleep.

What is Post-Traumatic Stress Disorder?
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. After traumatic events, such as death, an earthquake, war, car accidents, floods or fires, it is not uncommon for people to experience feelings of heightened fear, worry, sadness or anger. If the emotions persist, however, or become severe, or the person gets triggered into reliving the event in their daily life, this can affect the person’s ability to function and may be a sign of PTSD.

What is Social Phobia?
Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation, such as a fear of speaking in formal or informal situations, or eating or drinking in front of others. In its most severe form, social phobia may be so broad that a person experiences symptoms almost anytime they are around other people.

How are anxiety disorders diagnosed?
Primary care physicians and psychiatrists diagnose someone as having an anxiety disorder if symptoms occur for six months on more days than not, and significantly interfere with the person’s ability to function at home, work or school.

Doctors perform physical and psychological evaluations to rule out other causes for the symptoms of anxiety. Cardiovascular disease, thyroid problems, menopause, substance abuse and/or drug side effects, such as from steroids, may cause symptoms similar to those of an anxiety disorder.

What is stress?
Stress is a normal physical response to events that make one feel threatened or that upset one’s balance in some way. When the body senses danger—real or imagined—the body’s defenses kick into high gear in a rapid, automatic process known as the ‘fight-or-flight’ reaction, or the stress response. The nervous system responds by releasing a flood of stress hormones, including adrenaline and cortisol, that rouse the body for emergency action.

What is the impact of stress?
Stress during development has often been regarded as a potentially disruptive force, capable of inducing disease states if overly prolonged or exceedingly intense. It can also, however, favor resiliency and adaptive processing that are crucial to navigating a human life. Countless studies have indicated that severe neglect during infancy, both in humans and in laboratory animals, results in long-term abnormal development of biological systems involved in the regulation of emotions, but the response to stress is also a key driver to individual development. The biological system  responsible for physical reactions to a stressor not only coordinates immediate responses to external challenges but also functions as a tool that enables the characterization of an environment as favorable or threatening. Thus the stress response system promotes long-term adaptive processes that prepare the individual to cope with specific external challenges.

What are the main symptoms of stress in adults?
• Cognitive symptoms include memory problems; inability to concentrate; poor judgment; anxious or racing thoughts and constant worrying
• Emotional symptoms include moodiness; irritability or short temper; agitation; inability to relax; a feeling of overwhelm; a sense of loneliness and isolation
• Physical symptoms include aches and pains; diarrhea or constipation; nausea; dizziness; chest pain; rapid heartbeat
• Behavioral symptoms include eating more or less; sleeping too much or too little; isolating yourself from others; procrastinating or neglecting responsibilities; using alcohol, cigarettes, or drugs to relax; engaging in nervous habits (e.g., nail biting, pacing)

What are the symptoms of stress in children and teens?
Youth of all ages, but especially younger children, may find it difficult to recognize and verbalize when they are experiencing stress. For children, stress can manifest itself through changes in behavior. Common changes can include irritability, withdrawal from formerly pleasurable activities, routine expression of worries, excessive complaints about school, frequent crying, display of surprising fearful reactions, sepa ration anxiety, sleeping too much or too little, or eating too much or too little. With teens, while spending more time with and confiding in peers is a normal part of growing up, significantly avoiding parents, abandoning long-time friendships for a new set of peers, or expressing excessive hostility toward family members may indicate that the teen is experiencing significant stress.

What is resilience?
In the physical sciences, materials and objects are termed resilient if they resume their original shape upon being bent or stretched. In people, resilience refers to the ability to ‘bounce back’ after encountering difficulty.

Are there coping factors to help deal effectively with stress?
In their 20 years of treating and studying trauma survivors, Drs. Dennis Charney and Steven Southwick have identified ten common practices in people who have shown resilience in the face of extreme stress.
• Maintaining an optimistic but realistic outlook
• Facing fear (ability to confront one’s fears)
• Reliance upon own inner, moral compass
• Turning to religious or spiritual practices
• Seeking and accepting social support
• Imitation of sturdy role models
• Staying physically fit
• Staying mentally sharp
• Cognitive and emotional flexibility (finding a way to accept that which cannot be changed)
• Looking for meaning and opportunity in the midst of adversity

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