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Anxiety disorders

Last updated: February 4, 2025

Summarytoggle arrow icon

Anxiety disorders cover a broad spectrum of conditions characterized by excessive and persistent fear (an emotional response to real or perceived 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, 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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Overviewtoggle arrow icon

Description

  • Excessive and persistent fear (an emotional response to real or perceived 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
  • Anxiety disorders include generalized anxiety disorder, panic disorder, specific phobias, and selective mutism.

Comparison of anxiety disorders

Overview of the most important anxiety disorders
Characteristics Generalized anxiety disorder (GAD) Panic disorder Social anxiety disorder Specific phobias Agoraphobia Substance/medication-induced anxiety disorder

Clinical features

  • Excessive and persistent anxiety and/or fear
  • Pronounced fear and/or anxiety of social situations that involve scrutiny from others
  • Persistent and intense fears of particular situations or objects
  • Pronounced fear or anxiety of situations that are perceived as difficult to escape from
  • Prominent anxiety or panic attacks after using or stopping a substance/medication
Triggers
  • No definitive trigger or source
  • May not have an obvious trigger
  • Social interaction and/or performance of any actions in public
  • One or more specific situations or objects
  • Being in enclosed spaces or open public spaces
  • Crowds
  • Being alone
Duration of symptoms required for diagnosis
  • ≥ 6 months
  • Panic attacks: several minutes
  • Fear of subsequent attacks: ≥ 1 month
  • ≥ 6 months
  • ≥ 6 months
  • ≥ 6 months in ≥ 2 different situations
  • Within 1 month of using or stopping the substance/medication
Treatment of anxiety disorders

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Etiologytoggle arrow icon

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Generalized anxiety disordertoggle arrow icon

Definition

  • An anxiety disorder characterized by excessive and persistent anxiety for ≥ 6 months
  • Symptoms can be triggered in various situations, with or without an identifiable stressor, and cause significant social or occupational dysfunction.

Epidemiology [1]

Clinical features [2]

  • Prolonged, excessive, pervasive worrying and anxiety
  • Nervousness, restlessness
  • Irritability
  • Muscle tension
  • Somnolence, fatigue
  • Concentration difficulties
  • Insomnia
  • Medically unexplained physical symptoms (e.g., chest pain, racing heart)

Screening [4][5]

Diagnostics [2][9]

Approach

  • Consider GAD in those with a positive screening or who express pervasive worrying, anxiety, and/or medically unexplained physical symptoms.
  • Perform a complete patient history and physical examination.
  • Consider diagnostic studies to rule out organic causes.
  • Confirm the diagnosis using the DSM-5 criteria for GAD.
  • Assess for psychiatric and medical comorbidities, including substance use disorder.
  • Evaluate suicide risk.
  • Consult psychiatry if there is diagnostic uncertainty or concern for comorbid psychiatric conditions.

Up to 80% of individuals with GAD have a psychiatric comorbidity, e.g., major depressive disorder or social anxiety disorder. [1][2]

Exclusion of organic causes [2]

Consider the following studies based on clinical suspicion.

DSM-5 diagnostic criteria for GAD [3]

Diagnosis is confirmed in individuals who meet all of the following criteria.

  • Excessive anxiety and worry about multiple events and/or activities (e.g., school, work) on most days for ≥ 6 months
  • Worry that is difficult to control
  • ≥ 3 (in adults) or ≥ 1 (in children) of the following symptoms occurring on most days over the past 6 months:
    • Sleep disturbances
    • Muscle tension
    • Irritability
    • Difficulty concentrating
    • Fatiguing easily
    • Restlessness
  • Symptoms that cause significant distress or impairment in the professional, social, or other important areas
  • Symptoms not attributable to substance use, a medical disorder (e.g., pheochromocytoma, hyperthyroidism), or other psychiatric conditions (e.g., panic disorder, PTSD, somatic symptom and related disorders)

Differential diagnoses [2]

Management [2][9]

General principles

  • Therapeutic options for GAD are psychotherapy and/or pharmacotherapy.
  • Lifestyle modifications can help reduce and/or prevent symptoms.
  • Treatment response is measured using validated tools, e.g., GAD-7.
  • Consider indications for specialist referral, e.g., no improvement after first-line treatment.
  • Consider hospitalization for patients with intractable symptoms and/or suicidal ideation.

A combination of psychotherapy and pharmacotherapy is more effective than either treatment approach alone. [9]

Psychotherapy

Pharmacotherapy [2]

Cannabis can trigger psychiatric disorders, and there is no scientific evidence to recommend its use in patients with anxiety disorders. [9]

Long-term use of benzodiazepines is associated with significant adverse effects (e.g., motor and cognitive impairment) and risk of dependence. [2]

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Lifestyle modifications

Indications for referral

Refer to a psychiatrist in any of the following situations.

Special patient groups

Perinatal generalized anxiety disorder [10]

  • Definition: GAD that occurs during pregnancy and/or up to one year postpartum
  • Epidemiology: ∼ 10% prevalence [10]
  • Risk factors
  • Clinical features
    • Time-consuming, overwhelming, intrusive fears about illness, mortality, and well-being of the fetus, oneself, and the other parent
    • Functional impairment, such as inability to perform regular activities (in moderate to severe anxiety)
    • Physical symptoms (e.g., fatigue, insomnia, muscle tension)
    • Comorbid MDD (common)
  • Screening: Screen all pregnant and postpartum individuals using, e.g., GAD-7 , EPDS anxiety subscale [5][6][11]
  • Diagnostics: Confirm diagnosis using the DSM-5 criteria for GAD.
  • Treatment

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Acute panic attacktoggle arrow icon

Definition

An acute panic attack is an abrupt episode of intense fear associated with physical and cognitive symptoms. [12][13]

Etiology [3][12]

Clinical features [3]

Acute panic attacks peak within several minutes and involve ≥ 4 of the following cognitive and/or somatic symptoms:

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.

Diagnostics

Differential diagnoses

Consider the following based on the presenting clinical feature:

Management of acute panic attack [14][15]

Panic attacks typically self-resolve within 30 minutes of onset and may not require acute intervention. [14]

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Panic disordertoggle arrow icon

Definition

Panic disorder is an anxiety disorder characterized by recurrent, unexpected panic attacks in addition to a ≥ 1-month period of persistent worry about experiencing additional attacks or their consequences, and/or maladaptive behavior to avoid further episodes.

Epidemiology [16]

Etiology [9]

Clinical features [9]

Diagnostics [9]

Approach

Exclusion of organic causes

Consider the following studies based on clinical suspicion.

DSM-5 diagnostic criteria for panic disorder [3]

Diagnosis is confirmed in individuals who meet all of the following criteria.

Differential diagnoses [18]

Management [17][18]

See also “Management of acute panic attack.”

Patients with panic disorder are at increased risk of suicide. [9][18]

General principles

  • Treatment options for panic disorder are psychotherapy and/or pharmacotherapy.
  • Lifestyle modifications can help reduce symptoms.
  • Treatment response is measured using the Panic Disorder Severity Scale.
  • Consider indications for specialist referral, e.g., no improvement after first-line treatment.
  • Consider hospitalization for patients with intractable symptoms and/or suicidal ideation.

Psychotherapy [17][18]

  • CBT is the preferred modality.
  • Consider especially for patients who decline or do not tolerate pharmacotherapy.
  • Effectiveness is similar to pharmacotherapy.

Pharmacotherapy

Cannabis can trigger psychiatric disorders, and there is no scientific evidence to recommend its use in patients with anxiety disorders.

Long-term use of benzodiazepines is associated with an increased risk of tolerance, dependence, and withdrawal. [18]

Indications for referral

Refer to a psychiatrist in any of the following situations.

  • There is no improvement with first-line pharmacotherapy.
  • The patient does not tolerate pharmacotherapy.
  • The patient has comorbid psychiatric and/or substance use disorders.
  • Long-term benzodiazepines or alternative agents (e.g., TCAs) are being considered.
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Social anxiety disordertoggle arrow icon

Definition [3]

Social anxiety disorder is characterized by intense and disproportionate fear and/or anxiety of social situations in which the individual may be scrutinized or judged (e.g., meeting new people, parties, eating in public) that lasts for ≥ 6 months.

Epidemiology

Subtypes

  • Performance-only social anxiety disorder: : an anxiety disorder characterized by intense fear and/or anxiety related to speaking or performing in public
  • Paruresis (shy bladder syndrome): the inability to urinate in the presence of others [20]

Clinical features

  • 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 fear and/or anxiety triggers (e.g., not attending parties, refusing to attend school)
  • In children [3]
    • Refusing to speak at social events, crying, throwing a tantrum, clinging to caregiver
    • Symptoms occur both in peer settings and with adults.

Diagnostics [19]

Approach

  • Consider screening individuals with other psychiatric or substance use disorders by asking about:
    • Avoidance of social situations or activities
    • Feeling anxious or embarrassed in social situations
  • Confirm the diagnosis using the DSM-5 criteria.
  • Assess for comorbidities, e.g., MDD, substance use disorders.

Individuals with social anxiety disorder often do not seek medical care for their psychological symptoms.

DSM-5 diagnostic criteria for social anxiety disorder [3]

Diagnosis is confirmed in individuals who meet all of the following criteria.

  • Significant fear or anxiety related to social situations in which scrutiny by others is anticipated (e.g., conversing with or meeting unfamiliar people, eating or giving a speech in front of others)
  • Fear of behaving in ways that will lead to negative judgment by others
  • Fear or anxiety that is almost always triggered by social situations
  • Avoidance of or intense anxiety during social situations
  • Fear or anxiety that is disproportionate to the actual threat
  • Symptoms that persist for ≥ 6 months
  • Symptoms causing significant distress or functional impairment (e.g., social, occupational)
  • Symptoms not attributable to or better explained by substance use or another psychiatric or medical condition

Differential diagnoses [19]

Management [19][21]

Psychotherapy and pharmacotherapy can be offered together or alone based on patient preferences and clinical judgment.

CBT combined with pharmacotherapy provides more rapid and long-lasting improvement of social anxiety disorder than CBT alone. [19]

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Specific phobiastoggle arrow icon

  • Definition
    • 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
  • Epidemiology
    • Lifetime prevalence: up to 10% of the population [22]
    • The average age of onset depends on the specific phobia (e.g., animal phobias more commonly develop in early childhood).
    • > (2:1)
  • Common phobias
    • Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
    • Natural environment: heights (acrophobia), storms (astraphobia)
    • Blood-injection-injury: blood (hematophobia), needles (belonephobia), 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)
  • Treatment
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Agoraphobiatoggle arrow icon

  • 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
  • Epidemiology
    • > (2:1)
    • Age of onset: < 35 years (60–70% of cases)
  • Clinical features
    • 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.
  • Treatment

If a patient meets the criteria for panic disorder and agoraphobia, both conditions should be diagnosed.

References:[3]

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Hyperventilation syndrometoggle arrow icon

Background [26][27][28]

Clinical features [30]

Diagnostics [30][31]

Hyperventilation syndrome is a diagnosis of exclusion.

Differential diagnoses

See also “Differential diagnosis of dyspnea.”

Acute management [30]

Rebreathing into a paper bag can cause significant hypoxemia and is therefore not recommended. [32]

Abnormal findings on physical exam (e.g., jugular venous distention, wheezing, crackles, altered mental status) suggest a diagnosis other than hyperventilation syndrome.

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Substance/medication-induced anxiety disordertoggle arrow icon

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Anxiety due to another medical conditiontoggle arrow icon

Patients should be evaluated for medical conditions that can cause anxiety. Anxiety due to another medical condition is diagnosed if the condition was diagnosed before the onset of anxiety. Possible underlying conditions include:

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Separation anxiety disordertoggle arrow icon

  • Description: a disorder characterized by excessive fear, anxiety, or avoidance of separation from major attachment figures
    • Separation anxiety disorder differs from nonpathological separation anxiety in its intensity and effect on the social and academic life of the individual.
    • Separation anxiety is normal in children under a developmental age of 3 years. [37]
    • Typically develops after a stressful life event, usually involving some form of loss (e.g., death of a relative, parental divorce, change of school)
    • Onset: the condition can occur in, or persist into, adulthood and may have a debilitating effect on an individual's ability to work or socialize in the absence of attachment figures.
  • Diagnostic criteria (DSM-V) [3]
    • Fear of separation from major attachment figures, that is excessive for developmental level, involving at least 3 of the following features:
      • Recurrent and excessive distress prior to, or during, separation
      • Persistent worrying about the loss of attachment figures (e.g., due to illness, injury, or death)
      • Persistent worrying about separation due to the individual being lost, kidnapped, injured, or ill
      • Persistent reluctant to leave home due to fear of separation
      • Avoidance of being left alone (e.g., at home or elsewhere)
      • Avoidance of falling asleep, or sleeping away from home, without major attachment figure
      • Persistent nightmares about separation
      • Persistent somatic symptoms (e.g., headaches, nausea/vomiting, abdominal pain)
    • Duration: symptoms persist for at least 4 weeks in children/adolescents and 6 months in adults
    • Significant impairment of academic, social, and/or work life (e.g., often a precursor to school refusal)
    • Symptoms are not attributable to another psychiatric disorder (e.g., autism spectrum disorder, psychosis, other anxiety disorders).

Children under 3 years of age commonly undergo periods of separation anxiety from attachment figures as a normal part of their development. The diagnosis of separation anxiety disorder should only be considered if the symptoms become excessive for developmental level. [37]

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Selective mutismtoggle arrow icon

  • Description: a psychiatric disorder characterized by the inability to speak in specific social situations (e.g., during class)
    • Typically normal development of language and speech.
    • Onset: generally before 5 years of age, although may not become clinically relevant until the child is required to perform verbally (e.g., with the start of school)
  • Diagnostic criteria (DSM-V) [3]
    • Consistent inability to speak in specific social settings where speaking is expected (e.g., does not speak in class but speaks at home)
    • Interferes with academic or professional performance and social interaction
    • Duration of symptoms: at least 1 month
    • The inability to speak is not due to difficulties or discomfort with the spoken language expected in the social situation.
    • The inability to speak is not attributable to schizophrenia spectrum disorder or another psychotic disorder, autism spectrum disorder, or a communication disorder.
  • Treatment [39]
  • Complications: may coexist with social anxiety disorder and may also result in school refusal
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