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Anxiety Disorders

Anxiety problems are among the most common of all mental health problems and result in massive suffering, disability, and economic loss. Anxiety disorders are characterized by the experience of fear and anxiety that results in significant distress and impairment in functioning.

The most common types of anxiety problems are specific phobias, panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder, and post-traumatic stress disorder.

Specific Phobias

Specific phobias are specific fears about specific things and situations. Most specific phobias are natural fears; that is, they are about situations that would make most people at least a little anxious or nervous. However, the difference is that people with a specific phobia will experience a panic attack, or fear experiencing a panic attack, if they are exposed to the feared situation.

Common specific phobias include:

  • Heights
  • Enclosed spaces
  • Exposed places
  • Flying
  • Public speaking/performance anxiety (see social anxiety, below)
  • Spiders
  • Insects
  • Snakes; and
  • Blood and injury

Specific phobias are the most treatable of all anxiety problems and cognitive behavioural therapy (CBT) is the treatment of choice for specific phobias.

Panic Disorder

Panic disorder is characterized by the repeated experience of sudden and very intense feelings of fear, often experienced as terror. These panic attacks often seem to strike without warning or “out of the blue.”

People with panic disorder often can’t predict when an attack will happen. As a result, they often develop intense anxiety between episodes, as they worry about when and where their next panic attack will happen because it could be anytime or anywhere. At other times, people can predict when and where a panic attack will happen and then they learn to fear and avoid those situations (which results in conditions such as agoraphobia).

The symptoms of a panic attack include

  • Racing or pounding heart
  • Chest pain
  • Shortness of breath
  • Feeling of being smothered
  • Faintness, weakness or dizziness
  • Tightness in the chest
  • Feeling of being choked, tightness in the throat
  • Numbness or tingling
  • Feeling cold, hot or flushed
  • Sense of unreality or depersonalization; and
  • Fear of impending doom, loss of control

As a result of these intense symptoms, people experiencing a panic attack often believe that they are going to die from a heart attack or stroke or that they are losing their mind.

Panic attacks can happen at any time, even during sleep. People most often describe their attacks as having a sudden onset and peaking within ten minutes. However, others describe their attacks as building. When people experience repeated, unexpected panic attacks, they start to expect them and begin to avoid places and situations in which they have experienced them, for example, going to the mall, going shopping, driving a car, riding in elevators, riding the subway, going to class, going to movies. When people start to avoid activities to an extent that it causes significant distress and impairment in their social and occupational functioning, they have developed agoraphobia.

Cognitive behavioural therapy (CBT) is the most effective treatment for panic disorder, with or without agoraphobia. CBT is effective for 90% of people with panic disorder and early treatment can often stop the development of agoraphobia. Panic attacks and panic disorder often occur along with other problems, including depression, substance use, and other types of anxiety problems. In addition, the symptoms can be very similar to those of a heart attack, stroke or other medical problem, so it is important to consult your family doctor to rule out a physical cause for your symptoms. After that, a proper and thorough differential diagnostic assessment by a psychiatrist or psychologist is the first step towards effective treatment.

Social Anxiety Disorder

People with social anxiety disorder have an intense fear of becoming extremely anxious and being judged, embarrassed or humiliated in social and performance situations that may include:

  • Public speaking
  • Giving presentations
  • Talking to strangers
  • Making small talk
  • Being the centre of attention
  • Being observed while working, eating, drinking, or learning
  • Talking on the phone in the presence of others
  • Walking into a room late
  • Asserting themselves with people in authority; and
  • Dating

Many healthy people are shy or introverted. However, people with social anxiety disorder are more than “just a little shy.” They experience excruciating self-consciousness and panic attacks in social and performance situations. They are “painfully shy” and can be constantly worried and stressed about being embarrassed or humiliated. The dread of social and performance situations can start days, weeks, or months in advance. As a result, people avoid situations that they would like to be a part of and feel bad about this loss of social and occupational functioning. They often suffer from low self-esteem and are often also depressed.

Some people with social anxiety have specific fears, usually about public speaking or other kinds of performance such as music or dance. Other people experience a more generalized fear across a number of social and performance situations.

Social anxiety disorder leads to significant impairment in social and occupational functioning. For example, people with social anxiety are more likely to drop out of school and some people with social anxiety are too anxious to ask anyone out on a date.

Social anxiety disorder is a serious but treatable condition. Cognitive behavioural therapy (CBT) is the treatment with the most and best evidence for the treatment of social anxiety disorder. Because social anxiety can be secondary to other conditions and can also occur with substance use and other anxiety problems, the first step towards effective treatment is a proper and thorough differential diagnostic assessment by a psychiatrist or psychologist.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by chronic and extreme worry combined with persistent feelings of tension, nervousness or anxiousness. People with GAD often describe themselves being anxious and worried all of the time. They are always expecting something bad to happen and planning for the worst. They describe themselves as feeling “restless,” “keyed-up,” or “on edge.” The chronic anxiety of GAD is often associated with sleep difficulties, irritability, difficulty concentrating, muscle pain, tension headaches and stomach problems.

People with GAD often feel a sense of doom or dread. Even though they realize that their extreme anxiety is out of proportion to the reality of the situation, they find it difficult to control their worry.

Some people with GAD only worry about one thing. However, most people with GAD describe themselves as being “worried all the time about everything,” including health, relationships, work, school, finances, and the future.

By definition, GAD is a chronic problem. In order to be diagnosed with GAD a person has to have a worry problem that has interfered with their life and caused them significant distress for more than six months.

GAD can be a serious problem and the symptoms often occur along with symptoms of depression and other anxiety problems. Fortunately, GAD is very treatable with cognitive behavioural therapy (CBT). The first step towards effective CBT for GAD is a proper and thorough differential diagnostic assessment by a psychiatrist or psychologist.

Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent and disturbing intrusive thoughts, images or impulses (obsessions) that cause anxiety, and repetitive, ritualized behaviours that the person feels driven to perform to reduce the anxiety (compulsions). Most people with OCD experience both obsessions and compulsions, but it is possible to have only one or the other.

People with OCD are worried about bad things happening. The most common theme of their obsessions is worry about harm to self or others. However, the thoughts, impulses, or images are not simply excessive worries about real-life problems. People with OCD often describe their obsessions as “weird” and inappropriate. They will often describe their obsessions by first saying “I know this sounds weird/crazy, but I can’t stop thing about…”.

The most common themes of obsessions include:

  • Contamination by such things as dirt, germs, illness
  • Unwanted aggression – fear of harming oneself or others
  • Unwanted sexual thoughts
  • Doubts about identity
  • Guilt/responsibility – being responsible for something bad happening (e.g., starting a fire)
  • Scrupulosity – doing something morally wrong or a violation of religious doctrine, sin, blasphemy; and
  • Symmetry and order – things looking and feeling “just right.”

People with OCD try to avoid obsessing by avoiding the situations that trigger them. If they can’t avoid the situation, they try to ignore or suppress their thoughts, images or impulses. If they can’t do that, they try to neutralize them by engaging in compulsions. People with OCD engage in compulsions to stop the “bad thing” from happening. Engaging in compulsions usually brings some temporary relief from anxiety. However, for most people with OCD, compulsions cause even more anxiety in the long run, especially if they are very demanding or time consuming.

Common compulsions include excessive and/or ritualized:

  • Washing (hand washing, showering)
  • Cleaning (kitchen and bathroom)
  • Checking (locks, windows, doors, stove, appliances)
  • List-making
  • Ordering and arranging (books and clothes)
  • Counting (words, steps, stairs, windows, ceiling tiles, or floor tiles)
  • Repeating (words, phrases, or actions); and
  • Hoarding (acquiring, collecting and/or not discarding things)

Although most compulsions are observable behaviours (e.g., hand washing), some are not as they are performed as mental rituals; for example, neutralizing an obsessive thought with another by thinking something “good” after thinking something “bad.”

Although some people with OCD may suffer from only one type of obsession or compulsion, most people with OCD have multiple types of obsessions and compulsions.

People with OCD recognize that their obsessions and compulsions are the result of their anxiety and are senseless and excessive. However, because their obsessions make them so anxious, they feel driven to engage in their compulsions.

OCD is often difficult for people to understand, partly because the object of their obsessions is often “weird.” People with moderate to severe OCD are often in significant distress and depressed. Fortunately, OCD is very treatable with cognitive behavioural therapy (CBT). It is sometimes not so easy to tell the difference between OCD and other kinds of problems. The first step towards effective CBT for OCD is a proper and thorough differential diagnostic assessment by a psychiatrist or psychologist.

Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a trauma- and stress-related disorder that can develop after a person witnesses or experiences an extremely traumatic, tragic, horrifying or terrifying event that involves death, serious injury, sexual violence, assault, accident, or disaster. PTSD is always related to an external event.

Trauma can be experienced directly or witnessed. It can also be experienced indirectly through hearing about a close friend or relative who has experienced the event directly. PTSD can result when individuals experience repeated or extreme indirect exposure to traumatic experiences through experiencing, witnessing and having indirect exposure (common victims include soldiers, police officers, firefighters, Emergency Medical Service providers, and emergency room staff).

Most professionals with experience in treating PTSD recognize that people can experience PTSD-like reactions even though the events experienced do not technically meet criteria for a traumatic event as described above. People can experience PTSD-like reactions following such events as divorce, the loss of a loved one, infidelity, media exposure to traumatic events, and emotional abuse.

In addition to having experienced or witnessed a traumatic event, people with PTSD will have suffered for a month or more with the following symptoms:

Re-experiencing or intrusions:

  • Intrusive memories or thoughts related to the event
  • Nightmares related to the event
  • Flashbacks, having the compelling experience that the event is happening again; and
  • Psychological and physical reactivity triggered by reminders of the traumatic event, such as a person, place, situation, or anniversary Avoidance
  • People with PTSD will avoid people, situations, thoughts, feelings and memories related to the trauma

Negative alterations in mood or cognition:

People with PTSD often have symptoms of depression and experience a variety of difficulties with feeling depressed and being stuck in certain patterns of thinking and feeling. Basically, there is a decline in mood or disruption of thinking and feeling, which can include

  • Memory problems related exclusively to the event
  • Negative thoughts and beliefs about the self, other people and the future
  • A distorted sense of guilt related to the event
  • Getting stuck in severe emotions related to the event (e.g., horror, shame, sadness)
  • Severely reduced interest in activities that were part of normal pretrauma life; and
  • Feelings of isolation, detachment, and disconnectedness from others

Increased physiological arousal:

Following a traumatic event, people remain chronically anxious, “on edge” and “on alert.” The person’s anxiety and fear systems become and stay activated, as if preparing them for the next “bad thing” to happen. Symptoms of persistent hyperarousal include:

  • Sleep difficulties
  • Anger/irritability
  • Difficulty concentrating, attending, remembering
  • Being easily startled
  • Feeling unreal, dissociated or depersonalized; and
  • Hypervigilance

When people experience extreme physiological hyperarousal they may experience symptoms of dissociation including:

  • Depersonalization – feeling apart from or disconnected from oneself; and
  • Derealization – feeling apart from or disconnected from the world, as if the world isn’t real

In addition to lasting for a month or more, the symptoms of PTSD often cause severe distress and impairment in functioning. Fortunately, PTSD is a highly treatable condition and cognitive behavioural therapy (CBT) is the best treatment for it. However, PTSD is often associated with depression, other anxiety disorders, and substance use problems. Understanding these other problems in the context of PTSD is important. The first step towards effective CBT for PTSD is a proper and thorough differential diagnostic assessment by a psychiatrist or psychologist.

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