Anxiety Disorders and Anxiety Conditions: Recognizing Anxiety, Panic Disorder, Panic Attacks, Phobias, and Generalized Anxiety Disorder

Anxiety is considered a disorder when

• it occurs repeatedly in situations that do not actually pose any danger or threat and
• there is no physical cause for the anxiety (e.g., thyroid dysfunction or heart disease).

Those affected tend to avoid situations that cause them anxiety. As a result, many anxiety disorders lead to a significant reduction in quality of life and functioning. For example, people with social phobia rarely socialize and are unable to try many new things.

According to the ICD-10, anxiety disorders are classified into several clinical categories:

• Agoraphobia (F 40.0): Occurrence of anxiety attacks, as well as avoidance behavior when away from safe places (usually away from home). The anxiety is situation-specific and occurs, for example, in department stores, movie theaters, restaurants, while driving, at heights, etc.
• Social phobias (F 40.1): Severe, inappropriate anxiety in situations involving other people, or anxiety-induced avoidance of such situations. The primary fear is that of being humiliated, failing, or drawing unwanted attention. These fears are accompanied by autonomic reactions such as sweating, trembling, and blushing.
• Specific phobias (F 40.2): Anxiety-inducing objects include, for example, dogs, cats, spiders, and mice, or specific situations such as heights, enclosed spaces, flying, or even the sight of blood, blood draws, or injections.
• Panic Disorder (F 41.0): Acute anxiety attacks occurring in time-limited episodes, often accompanied by physical symptoms such as heart palpitations, rapid heartbeat, shortness of breath, dizziness, lightheadedness, sweating, and a feeling of pressure or tightness in the chest
• Generalized Anxiety Disorder (F 41.1): Anxiety that persists for more than 6 months. It affects various areas of life, and those affected find it difficult to control. As a result, these worries often take up a large part of the day and lead to tension, sleep disturbances, difficulty concentrating, and other symptoms.

If left untreated, anxiety disorders often become chronic. Depression frequently accompanies them. Due to the common use of addictive sedatives, substance use disorders may also develop.

Pathological fears often manifest in all kinds of stressful situations. People with anxiety disorders frequently have an anxious parent as a “role model.” These fears solidify into a disorder when those affected begin to avoid situations that trigger anxiety.

Most anxiety disorders respond well to outpatient behavioral therapy. Treatment begins with identifying a model to explain the anxiety.

An integral part of treatment is systematically exposing those affected to anxiety-provoking situations. Together with their therapist, they seek out precisely those situations they would normally avoid due to their anxiety. These might include, for example,

• crowds,
• tall towers, and
• social situations

. Experience shows that anxiety can be effectively reduced in this way. In addition, those affected often need to learn to better recognize sources of stress and reduce their stress levels.

Isolated panic attacks do not yet constitute a panic disorder. A panic disorder is present when the panic causes distress in those affected and interferes with their daily lives.

Symptoms of a panic disorder

For those affected, panic attacks seem to come out of the blue, at least at first.

They manifest as symptoms that can be quite dramatic, such as

• rapid heartbeat,
• dizziness,
• weakness,
• shortness of breath,
• sweating, or
• diarrhea.

Added to this are severe fears, such as

• having a heart attack or stroke,
• fainting, or
• going crazy.

These symptoms are often exacerbated by hyperventilation. During this process, those affected breathe very rapidly and consequently take in too much oxygen. In most cases, those affected flee situations in which panic attacks occur.

Panic attacks vary in duration, but usually last no longer than 30 minutes.

Agoraphobia is diagnosed when those affected avoid certain places—such as

• department stores,
• movie theaters,
• public transportation,
• crowded places, and the like.

Those affected experience an almost constant fear of new panic attacks (anticipatory anxiety). This condition severely limits their ability to function and their freedom of movement. They are fully aware that their fear is irrational.

Prevalence of Panic Disorders

Approximately 15 to 30 percent of all people experience a panic attack at least once in their lives. However, only about 3 percent go on to develop a panic disorder, with women being affected about twice as often as men. It usually begins in young adulthood.

Treatment of Panic Disorders

Panic disorders are most successfully treated with behavioral psychotherapy. As mentioned above, the most important component of therapy is exposure to the situations that trigger anxiety.

Many people with panic disorder also experience support and relief as a result of their panic attacks. For example, family members might do their shopping for them, or their partner might accompany them more often, etc.

It is often extremely difficult for those affected to directly ask for support and relief. In relationships, panic disorder patients often feel that their needs are not being met in some way. Such issues must be addressed in therapy.

Medications, particularly serotonergic antidepressants, can also be used to treat panic disorders. Due to their high risk of dependence, sedatives such as benzodiazepines (e.g., Tavor®) should only be prescribed temporarily for a short period of time.

Case Study: Panic Disorder

A 35-year-old woman—employed, married, and the mother of a son—is referred by her primary care physician to a behavioral therapy outpatient clinic after thorough and repeated organic evaluations revealed no evidence of a physical illness.

For the past two years, she has been suffering from recurring, overwhelming feelings of fear of death and panic. This first occurred when she visited her uncle in the intensive care unit after he had suffered a completely unexpected heart attack. She had been very nervous, had to wait outside the ward for quite some time, and drank two cups of coffee during that period. When she finally stood before her uncle, who was lying there completely lifeless, she was overcome with terrible fear. She also felt as if she were about to faint, so she had to leave the ward quickly.

Since then, the anxiety has always surfaced whenever she has contact with her uncle’s family. It also manifests itself in doctors’ offices and hospitals, and for the past few months, even in the city, in department stores, and in crowded places. By now, she can no longer take her son to the doctor alone and can barely go shopping by herself.

The patient is helped to understand that while panic attacks are extremely unpleasant, they are not dangerous. She begins—initially with therapeutic support—to deliberately seek out situations in which she experiences panic. She notices that the panic attacks, which were severe at the outset, become less intense with each exercise. After 9 months, the patient’s daily life is once again completely unaffected, and she experiences only mild bouts of panic.

In social phobia, the main problem is fear of and avoidance of “public” situations, e.g.,

• eating with others,
• giving presentations,
• attending private or professional events or parties.

Those affected are primarily afraid of embarrassing themselves or being judged negatively by others. In addition to typical anxiety symptoms similar to those of a panic attack, blushing or trembling often occur in these feared situations.

Many people are shy. Social phobia, however, exists when

• those affected no longer expose themselves to such situations at all or
• can only endure these situations while experiencing intense anxiety.

Social phobias are very common. About 13 percent of all people are affected, with women slightly more likely to be affected than men. It usually begins as early as school age.

Those particularly affected are people who have always been prone to severe self-doubt and who, at the same time, set high standards for themselves. They pay close attention to what is going on inside them (“heightened self-awareness”).

Behavioral therapy often involves exposure to the anxiety-provoking situation. In addition, training in social skills is a key focus, such as

• learning to assert oneself,
• learning to say “no,”
• learning to accept one’s own mistakes.

Group therapy is ideal, as patients can support one another. At the same time, being in a group automatically exposes them to one of their feared situations.

A specific phobia is present when the affected person has a fear of a specific

• object (e.g., spiders, insects, dogs) or
• situation (e.g., a cramped elevator, thunderstorms, flying, a visit to the dentist)

. Such fear is only classified as a disorder if it limits the affected person’s ability to cope with daily life. This would be the case, for example, with a business traveler who has a fear of flying.

Such limiting phobias can be treated very effectively through exposure to the feared situation.

People with generalized anxiety disorder ruminate a great deal, worrying anxiously about everyday matters. They worry about their own well-being and that of their family, even when there is no actual cause for concern.

As a result, they are constantly anxious and tense and can hardly bring this state to an end on their own. It is only considered a disorder when the symptoms have persisted for more than half a year.

Approximately 5 percent of the population is affected, with women being affected more frequently than men. Generalized anxiety disorder usually begins in adolescence or early adulthood.

Those affected usually do not seek psychotherapy right away. They suspect physical illnesses and therefore repeatedly consult their primary care physicians and other medical specialists.

From a psychotherapeutic perspective, cognitive therapy is particularly indicated for generalized anxiety disorder. In this therapy,

• those affected learn that their ruminations and worries are one-sided and overly pessimistic,
• they specifically practice using different thoughts, and
• acquire better problem-solving strategies as well as anxiety-management strategies such as distraction or regular relaxation training.

However, this therapy is less successful than exposure therapy for more specific fears.