Learning Objectives
- Describe how generalized anxiety disorder presents.
- Describe how specific phobia presents.
- Describe how agoraphobia presents.
- Describe how social anxiety disorder presents.
- Describe how panic disorder presents.
The hallmark symptoms of anxiety-related disorders are excessive fear and anxiety and related behavioral disturbances. How do we distinguish fear from anxiety? The DSM says that fear is an emotional response to a real or perceived imminent threat which leads to “…surges of autonomic arousal necessary for flight or flight, thoughts of immediate danger, and escape behaviors.” Anxiety, on the other hand, is the anticipation of a future threat leading to, “…muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors” (APA, 2022, pg. 215). The anxiety disorders differ from one another in the types of objects or situations that lead to fear, anxiety, or avoidance behavior. We will cover generalized anxiety disorder, specific phobia, agoraphobia, social anxiety disorder, and panic disorder.
Generalized Anxiety Disorder
Generalized anxiety disorder is characterized by an underlying excessive anxiety and worry related to a wide range of events or activities and lasting for more days than not for at least six months. While many individuals experience some degree of worry throughout the day, individuals with generalized anxiety disorder experience worry of greater intensity and for longer periods than the average person (APA, 2022). Additionally, they are often unable to control their worry through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks. To receive a diagnosis of generalized anxiety disorder, three or more of the following somatic symptoms must be present in adults as well: restlessness, fatigue, difficultly concentrating, irritability, muscle tension, and problems sleeping (APA, 2022; Gelenberg, 2000).
Specific Phobia
Specific phobia is distinguished by fear or anxiety specific to an object or a situation. While the amount of fear or anxiety related to the specific object or situation varies among individuals, it also varies related to the proximity of the object or situation. When individuals are face-to-face with their specific phobia, immediate fear is present, and the phobic object or situation is actively avoided or endured. It should also be noted that these fears are excessive and irrational, often severely impacting one’s daily functioning. The fear, anxiety, or avoidance is persistent, lasting at least six months (APA, 2022).
Individuals can experience multiple specific phobias at the same time. In fact, nearly 75% of individuals with a specific phobia report fear of more than one object and the average individual fears three or more objects or situations (APA, 2022). When making a diagnosis of specific phobia, it is important to identify the stimulus. Among the most diagnosed specific phobias are animals, natural environment (height, storms, water), blood-injection-injury (needles, invasive medical procedures), or situational (airplanes, elevators, enclosed places). In terms of gender differences, women predominantly experience animal, natural environment, and situational specific phobias while blood-injection-injury phobia is experienced by both men and women equally (APA, 2022).
Agoraphobia
Agoraphobia is defined as intense fear or anxiety triggered by two or more of the following: using public transportation such as planes, trains, ships, buses; being in large, open spaces such as parking lots or on bridges; being in enclosed spaces like stores or movie theaters; being in a crowd or standing in line; or being outside of the home alone. The individual fears or avoids these situations because they believe something terrible may occur and due to concern over not being able to escape or help not being available (APA, 2022). Active avoidance of the situations occurs and can be behavioral such as changing daily routines or using delivery to avoid entering a restaurant or cognitive such as using distraction to bear with an agoraphobic situation. The avoidance can result in the person being homebound. The fear or anxiety is out of proportion to the actual danger they pose and has been present for at least six months.
Social Anxiety Disorder
For social anxiety disorder, the anxiety or fear relates to social situations, particularly those in which an individual can be evaluated by others. More specifically, the individual is worried that they will be judged negatively and viewed as stupid, anxious, crazy, boring, or unlikeable, to name a few. Some individuals report feeling concerned that their anxiety symptoms will be obvious to others via blushing, stuttering, sweating, trembling, etc. These fears severely limit an individual’s behavior in social settings and have occurred for six months or more.
To explain social anxiety in greater detail, let’s review the story of Mary. Mary reported the onset of her social anxiety disorder in early elementary school when teachers would call on students to read parts of their textbook aloud. Mary stated that she was fearful of making mistakes while reading and to alleviate this anxiety, she would read several sections ahead of the class to prepare for her turn to read aloud. Despite her preparedness, one day in 5th grade, Mary was called to read, and she stumbled on a few words. While none of her classmates realized her mistake, Mary was extremely embarrassed and reported higher levels of anxiety during future read aloud moments in school. In fact, when she was called upon, Mary stated she would completely freeze up and not talk at all. After a few moments of not speaking, her teacher would skip Mary and ask another student to read her section. It took several years and a very supportive teacher for Mary to begin reading aloud in class again.
Like Mary, individuals with social anxiety disorder report that all or nearly all social situations provoke this intense fear. Some individuals even report significant anticipatory fear days or weeks before a social event is to occur. This anticipatory fear often leads to avoidance of social events in some individuals; others will attend social events with a marked fear of possible threats. Because of these fears, there is a significant impact on one’s social and occupational functioning.
It is important to note that the cognitive interpretation of these social events is often excessive and out of proportion to the actual risk of being negatively evaluated. As we saw in Mary’s case, when she stumbled upon her words while reading to the class, none of her peers even noticed her mistake. Situations in which individuals experience anxiety toward a real threat, such as bullying or ostracizing, would not be diagnosed with social anxiety disorder as the negative evaluation and threat are real.
Panic Disorder
Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks. A panic attack is defined as a sudden or abrupt surge of fear or impending doom along with at least four physical or cognitive symptoms. Physical symptoms include heart palpitations, sweating, trembling or shaking, shortness of breath, feeling as though they are being choked, chest pain, nausea, dizziness, chills or heat sensations, and numbness/tingling. Cognitive symptoms may consist of feelings of derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself), the fear of losing control or ‘going crazy,’ or the fear of dying (APA, 2022). While symptoms generally peak within a few minutes, it seems much longer for the individual experiencing the panic attack.
There are two key components to panic disorder—the attacks are unexpected, meaning there is nothing that triggers them, and they are recurrent, meaning they occur multiple times. Because these panic attacks occur frequently and are primarily “out of the blue,” they cause significant worry or anxiety in the individual as they are unsure of when the next attack will happen. In contrast to unexpected there are also expected panic attacks, or those that have an obvious trigger. The DSM-5-TR states that presence of expected panic attacks does not rule out the diagnosis of panic disorder as about half of individuals diagnosed with the disorder in the United States and Europe have both types of attacks (APA, 2022).
In some individuals, significant behavioral changes such as fear of leaving their home or attending large events occur as the individual is fearful an attack will happen in one of these situations, causing embarrassment. Additionally, individuals report worry that others will think they are “going crazy” or losing control if they were to observe an individual experiencing a panic attack. Occasionally, an additional diagnosis of agoraphobia is given to an individual with panic disorder if their behaviors meet diagnostic criteria for this disorder as well.
The frequency and intensity of these panic attacks vary widely among individuals. Some people report panic attacks occurring once a week for months on end, others report more frequent attacks multiple times a day, but then experience weeks or months without any attacks. The intensity of symptoms also varies among individuals, with some patients experiencing four or more symptoms (full-symptom) or less than four (limited-symptom. Furthermore, individuals report variability within their panic attack symptoms, with some panic attacks presenting with more symptoms than others. To be diagnosed with panic disorder, the individual must present with more than one unexpected full-symptom panic attack (APA, 2022).
Key Takeaways
You should have learned the following in this section:
- All anxiety disorders share the hallmark symptoms of excessive fear or worry related to behavioral disturbances.
- Generalized anxiety disorder is characterized by an underlying excessive worry related to a wide range of events or activities and an inability to control their worry through coping strategies.
- Specific phobia is characterized by fear or anxiety specific to an object or a situation and individuals can experience fear of more than one object.
- Agoraphobia is characterized by intense fear related to situations in which the individual is in public situations where escape may be difficult and help may not be able to come.
- Social anxiety disorder is characterized by fear or anxiety related to social situations, especially when evaluation by others is possible.
- Panic disorder is characterized by a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks.
Review Questions
- What is the difference between fear and anxiety?
- What are the key differences between generalized anxiety disorder and agoraphobia?
- Individuals with social anxiety disorder will experience both physical and cognitive symptoms, particularly when presented with social interactions. What are these symptoms?
- What are the common types of specific phobias?
- What are the physical and cognitive symptoms observed during panic disorder?
- What are the key components of panic disorder?
