The definition and conceptualization of anxiety has undergone a change since its original clinical inception by pioneers in psychology and psychiatry like Sigmund Freud. According to the scholarly book that is often used as a companion to the APA’s series of texts Kaplan and Sadock’s Synopsis of Psychiatry, the differentiation between anxiety, fear, and anxiety disorders include the following:
- Fear represents an emotional response to a real or imagined imminent threat.
- Anxiety represents an emotional response to some perceived future threat.
- Anxiety disorders represent psychological disorders that share features of excessive anxieties and/or fear.
- The determination of what constitutes excessive anxiety or fear is based on the notions of state and trait anxiety.
- Trait anxiety refers to the personalized internal feelings that everyone has, but differs in when people experience anxiety or fear in accordance with the same or similar threatening situation.
- State anxiety refers to the overall duration of the fearful anxious episodes, such that when a threat is present or perceived to be imminent, individuals experience anxiety or fear, and when the threat is removed, the anxiety or fear should dissipate.
- Individuals with anxiety disorders experience state anxiety for periods far longer than would be expected under normal circumstances given the same level of threat, and they experience far more intense feelings of anxiety/fear than expected given the nature of the real or perceived threat.
Thus, individuals who have anxiety disorders experience far more intense anxiety than would be expected in a particular situation and often experience of anxiety for far longer than would be expected given a particular situation. In addition, individuals who experience fear will typically have both their fight-or-flight mechanisms activated (depending on the circumstance), whereas individuals experiencing anxiety typically only have their flight mechanisms activated.
In individuals with anxiety disorders, the activation of the flight mechanism is due to changes in the autonomic nervous system (ANS). When prolonged, these ANS changes can be detrimental to both one’s emotional and physical wellbeing. For example, long-term activation of the flight mechanism results in the release of hormones, such as corticosteroids, that prepare an individual to escape in the short-term by increasing certain bodily functions and by decreasing actions of others. These changes are designed for short-term responses, and these hormones also have long-term damaging effects on areas of the central nervous system.
The major types of anxiety disorders are briefly discussed below. These descriptions are taken from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition. For all of the anxiety disorders, the behavior that is displayed by the individual must seriously impact their ability to function in their daily life. The behaviors resulting from them cannot be better explained by some other disorder (e.g., other mental health disorders, some cognitive problems such as those associated with a developmental problem or a head injury, or some other medical condition) and/or the use of drugs or medications.
Separation Anxiety Disorder
Separation anxiety disorder occurs when someone displays fear or anxiety that is considered to be inappropriate for being separated from a person (excessive given their age and level of cognitive/emotional development).
These episodes of an appropriate fear or anxiety are typically displayed by a consistent presentation that includes four or more of the following:
- Recurrent episodes of excessive distress when either being separated from the person or when they anticipate being separated from the person or from their home
- Recurrent episodes of excessive worry about losing major figures to whom they are attached
- Recurrent episodes of excessive worry about some event that will lead to separation from the person or home
- Recurrently refusing to leave the home or the person (e.g., a teacher at school) due to the fear of being separated
- Recurrently being fearful of being left alone
- Recurrent episodes of refusing to sleep away from the person or place
- Recurrent nightmares about separation
- Recurrently complaining of being ill when they perceive that they will be separated from the person
The duration of these reoccurring anxious or fearful episodes must be at least four weeks in children and adolescents, and six months or more in adults. Children will typically go through a developmental period that is formally defined and predictable where separation anxiety is common, and young children displaying separation anxiety as a result of normal development are not diagnosed with this disorder. This is a rather common disorder occurring in children (with the prevalence of about 4 percent of all children). It is less common in adults.
Phobias are excessive fears or anxieties about a specific situation or object that are considered to be markedly disproportional to the actual threat involved. The feared object or situation almost always provokes an immediate fear response or anxiety reaction.
The result of the fear or anxiety leads to a number of dysfunctional behaviors aimed at avoiding the situation or object in question.
The person must display these behaviors as well as the excessive fear for at least six months.
Of course, there are a number of different phobias recognized, the majority of which actually represent potentially threatening situations or objects, such as snakes, spiders, flying, being in enclosed spaces, etc. It very rare to see phobic reactions to benign objects or events, such as phobias directed at things like chairs.
Social Anxiety Disorder (Social Phobia)
Social anxiety disorder is characterized by having an excessive anxiety or fear concerning at least one social situation where the person will be scrutinized by other people. These situations can include things like being with unfamiliar people for the first time, being watched when one is eating, and, of course, actually performing in front of others, such as speaking in public. Individuals with social anxiety disorder most often feel that they will be humiliated as a result of these interactions and will typically avoid these situations. If forced to perform, they will generally do so under extreme duress.
The experience of anxiety in these cases must be well out of proportion to the actual threat involved in the particular situation and also be markedly excessive when considered in terms of how most people feel in the same situation. For instance, the majority of people become anxious when having to give a speech in front of others; however, in order for a diagnosis of social anxiety disorder to be made in this situation, the individual must display rather extreme fearful or anxious behaviors as well as a number of dysfunctional behaviors associated with avoiding or trying to cope with the situation.
Panic disorder consists of two major features:
- Experiencing recurrent unexpected panic attacks
- Displaying for at least one month or longer periods of excessive worrying about experiencing another attack and/or engaging in maladaptive behaviors designed to avoid having future attacks
Panic attacks are extreme and intense periods of anxiety or fear that affect both the individual’s physical functioning (e.g., pounding heart, sweating, trembling, sensations of choking or being unable to breathe, extreme nausea, dizziness, chills, chest pains, etc.) and emotional functioning (e.g., feeling as if one is going crazy, feeling as if one is detached from reality, the sensation that one is detached from one’s own body, fear of losing control, or fear of dying). The number of individuals who experience occasional panic attacks, or anxiety attacks as many call them, is actually relatively high. Most people do not develop panic disorder as a result of experiencing these brief periods of extreme anxiety. Individuals who have repeated panic attacks and attempt to cope with them in a dysfunctional manner are diagnosed with this disorder.
It is important to mention that a number of different physical and mental conditions can be associated with panic attacks. Individuals experiencing repeated panic attacks should have a full physical evaluation as they may be a sign of an endocrine issue (e.g., thyroid condition), cardiovascular problem, or some other serious medical problem. If an individual is experiencing panic attacks that can be associated with a specific physical disorder, such as a heart condition, the physical condition should be addressed as opposed to attempting to use a psychiatric or psychological approach to treatment.
Agoraphobia is a condition that was previously most often associated with the development of panic disorder; however, it has become a standalone diagnosis. Agoraphobia consists of a fear or extreme anxiety about being in two or more different situations where one believes that they cannot escape. These situations include:
- Being in open spaces
- Being in a crowd
- Being outside of one’s home alone
- Being in some form of public transportation
- Being in some enclosed place, including stores, theaters, etc.
Often, the person experiences symptoms that are very similar to symptoms of a panic attack when either thinking about or being in the situation.
Generalized Anxiety Disorder
General anxiety disorder is a disorder that is considered to be chronic (must occur most days for at least six months) and represents excessive fear or anxiety (or apprehension) about many different types of events. People with generalized anxiety disorder are often considered to be worrywarts or neurotic in that they just seem to worry about everything and are anxious about everything.
APA notes six specific symptoms that must be expressed over a six-month period in these individuals. Adults must consistently express three of them, whereas children only need to express one symptom over a six-month time period.
The situations include:
- Constant restlessness or feeling on edge
- Constant difficulties with concentrating or with attention
- Constantly feeling fatigued or fatiguing very easily
- Constantly experiencing muscle tension
- Consistent expressions of irritability or restlessness
- Constantly experiencing problems with sleeping