Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent fear (an emotional response to imminent threats), anxiety (the anticipation of a future threat), worry (apprehensive expectation), and/or avoidance behavior. The etiology of anxiety disorders is multifactorial and may involve genetic, developmental, environmental, neurobiological, cognitive, and psychosocial factors. Therapy typically consists of a combination of pharmacotherapy, especially selective serotonin reuptake inhibitors (SSRIs), and psychotherapy, especially cognitive-behavioral therapy (CBT).
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- Excessive and persistent fear; (an emotional response to imminent threats), anxiety; (the anticipation of a future threat), worry; (apprehensive expectation), and/or avoidance behavior
- Physical manifestations that are disproportionate to the real magnitude of the trigger
- Not due to substance abuse, medical disorder (e.g. pheochromocytoma, hyperthyroidism), or other psychiatric conditions
- Anxiety disorders include panic disorder, phobias, generalized anxiety disorder, and selective mutism (for selective mutism see “emotional and behavioral disorders in children and adolescents”).
|Overview of the most important anxiety disorders|
|Generalized anxiety disorder (GAD)||Panic disorder||Social anxiety disorder (SAD)||Specific phobias||Agoraphobia||Substance/medication-induced anxiety disorder|
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|Triggers|| || || || || |
|Duration of symptoms required for diagnosis|| || || || || || |
- Neurobiological factors
- Substance use (leading to substance/medication-induced anxiety disorder)
- Environmental and developmental factors
- Other medical conditions: conditions that may lead to anxiety and/or panic attacks
Definition: prolonged and excessive anxiety that:
- Is not focused on a single specific fear but may revolve around certain themes (e.g., health, work)
- Causes clinically significant distress
- Is not caused by substance use, medication, or underlying medical condition
- Epidemiology 
- Clinical features: diagnosis is confirmed if the following symptoms occur more days than not for at least 6 months (≥ 1 symptom in children, ≥ 3 in adults)
- Panic disorder
- Depressive disorders
- SAD: Patients with GAD are usually comfortable in social situations and not particularly disturbed by the evaluation by others.
- First-line: psychotherapy, pharmacotherapy, or both
- Benzodiazepines can be used until SSRIs take effect but should never be used for long-term management, as they increase the risk of .
- Antipsychotics only for refractory cases
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- Definition: recurrent spontaneous and unexpected panic attacks that often occur without a known trigger
- Epidemiology 
- Recurrent panic attacks: episodes of intense fear and discomfort that peak within several minutes
- Diagnostics: recurrent panic attacks, at least one of which is followed by ≥ 1 of the following:
- Complication: Risk of suicide is increased.
“STUDENTS FEAR the 3Cs”: Sweating, Trembling, Unsteadiness (dizziness), Derealization, Elevated heart rate (palpitations), Nausea, Tingling, and Shortness of breath; FEAR of dying or going crazy; Chest pain, Choking, and Chills.
- Definition: pronounced anxiety lasting ≥ 6 months of social situations that might involve scrutiny by others
- Social anxiety disorder (SAD): fear/anxiety out of proportion to a social situation where one may be scrutinized by others (e.g., meeting new people at a party, eating in public)
- Performance-only SAD: symptoms of fear/anxiety restricted only to public speaking or performing in front of crowds
- Paruresis (shy bladder syndrome): fear/anxiety associated with urinating when other people are present, e.g., in public restrooms
- Blushing, palpitations, sweating during a social interaction
- Anticipatory anxiety (e.g., worrying weeks in advance about attending a social event)
- Anxiety driven by fear of embarrassment and others noticing the reaction
- Avoidance of the aforementioned triggers (e.g., not attending parties, refusing to attend school)
- In children: refusing to speak at social events, crying/throwing a tantrum, clinging to their caregiver
- CBT for SAD and performance-only SAD
- Pharmacotherapy for SAD
Pharmacotherapy for performance-only SAD: beta blockers (e.g., propranolol) OR (e.g., )
- Given on an as-needed basis
- Taken 30–60 minutes before an anxiety-causing event
- Persistent (≥ 6 months)and intense fears of one or more specific situations or objects (phobic stimuli)
- Always occurs during encounters with the phobic stimulus but may already surge in anticipation of an encounter
- Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
- Natural environment: heights (acrophobia), storms (astraphobia)
- Blood-injection-injury: blood (), needles (blenophobia), dental procedures (odontophobia), fear of injury (traumatophobia)
- Situational: enclosed places (claustrophobia), flying (aviophobia)
- Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia), costumed characters (masklophobia), fear of clowns (coulrophobia)
- Definition: pronounced fear or anxiety of being in situations that are perceived as difficult to escape from or situations in which it might be difficult to seek help
Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd
- Being outside of the home alone
- Active avoidance of these settings unless a companion is present
- Fear can become so severe that the affected individual feels unable to leave the house.
- Some patients can have comorbid panic disorder.
- Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
- Cognitive-behavioral therapy
- Selective serotonin reuptake inhibitors
- Definition: prominent anxiety or panic attacks within 1 month of use of, or withdrawal from, a substance/medication that is capable of inducing anxiety symptoms 
- Etiology 
- Clinical features