The following brief descriptions are intended to distill some salient points that serve to distinguish the disorders from each other. Keep in mind that the symptoms of anxiety often manifest as a waxing and waning “blanket” of symptoms but may also include time-limited “bursts” of symptoms in the form of panic attacks. Panic attacks, sometimes referred to as “anxiety attacks,” are in themselves not considered a separate anxiety disorder. These attacks are required for the diagnosis of panic disorder when they occur spontaneously but may occur with other anxiety disorders in response to situational triggers. In a typical panic attack, patients experience a sudden onset of symptoms that typically peak
within 10 minutes and rarely last longer than an hour. During a panic attack, psychological symptoms often include fears of losing control, dying, or “going crazy.” Physical symptoms reflecting autonomic activation are equally intense and include a racing heart rate, sweating, shaking, shortness of breath, nausea, dizziness, and chest discomfort.
Differentiating among the anxiety disorders relies on distinguishing if these symptoms, including panic attacks, are precipitated by specific situational triggers or are pervasive and occur with a variety of events (
Figure 4.1). The two disorders without specific situational triggers are panic disorder and generalized anxiety disorder. The disorders with specific situational triggers are social phobia, specific phobia, obsessive compulsive disorder, acute stress disorder, and posttraumatic stress disorder. Adjustment disorder with anxiety and anxiety disorder not otherwise specified are quite common and will be discussed separately.
Disorders without a Situational Trigger
Panic Disorder Panic disorder (
PD) is characterized by
recurrent panic attacks that are experienced at least initially as spontaneous and unexpected. Careful review with the patient may reveal benign cues such as emotional stress from an argument or a slightly elevated heart rate from caffeine that is interpreted as a symptom of an impending attack.
Although panic attacks can be terrifying and temporarily disabling, it is the
anticipatory anxiety of when the next attack will come and the
worry about its implications that perpetuates the disability. Patients may undergo extensive testing to find the etiology of symptoms, such as chest discomfort or gastrointestinal symptoms, before a diagnosis of
PD is made.
PD is twice as common in women as in men and onset peaks in late adolescence and the mid-30s. Although the initial panic attack is by definition not caused by an obvious trigger, the majority of patients report some antecedent adverse life event in the year prior to onset of illness.
Over time, agoraphobia may develop when continued apprehension of a panic attack prevents patients from being in places or situations from which they cannot escape, where help is unavailable, or where it would be embarrassing to be seen in the throes of a panic attack. In this respect, panic disorder with agoraphobia can be thought of as an anxiety disorder with a situational trigger. Common avoided places include buses, trains, supermarkets, and traveling away from home. In severe cases, patients may be completely housebound. Those
who manage to leave the home usually engage in compensatory behavior such as having a companion around for activities outside the house.
Generalized Anxiety Disorder Generalized anxiety disorder (
GAD) is the other anxiety disorder that does not have a specific situational trigger. In fact, the hallmark of
GAD is the lack of a central trigger and the presence of
free-floating anxiety consisting of ruminations and worries over often trivial matters that are pervasive and excessive. Along with these psychological symptoms are physical symptoms such as muscle tension, restlessness, and fatigue. Symptoms have been present for
at least 6 months, but many patients will describe themselves as
chronic worriers.
GAD may be relatively common among primary care patients whose main clinical problem is chronic insomnia.
Disorders with a Situational Trigger
Social Phobia Social phobia, also known as social anxiety disorder (SAD), is sometimes thought of as pathologic shyness. The hallmark is the fear of embarrassment or humiliation in front of others. This fear may be relatively mild and circumscribed to a specific situation such as public speaking or more severe and generalized to almost all social situations. Patients may report fears they will be negatively evaluated by others and “say something stupid” or fear that others will notice their physical symptoms such as blushing, sweating, or shaking. Panic attacks may occur but are situationally bound to the social trigger. Onset is usually in the early teenage years and patients will often have symptoms for over 10 years before seeking treatment. During this time important social activities may have been missed and job promotions avoided.
Obsessive Compulsive Disorder The hallmark of obsessive compulsive disorder (
OCD) is the presence of obsessions and/or compulsions that serve as triggers for anxiety.
Obsessions are
recurrent, unwanted, and
intrusive ideas, thoughts, impulses, or images. Common themes include contamination, repeated doubts, need for order, horrific thoughts, and sexual imagery.
Compulsions are
ritualistic behaviors or mental acts carried out in response to an obsession. Examples include repeated handwashing, checking of locks, and counting.
Those with true compulsions are differentiated from “compulsive” shoppers, gamblers, drinkers, etc., because the latter group derives some pleasure from the activity. These obsessions and compulsions are usually quite distressing for the patient and consume at least 1 hour per day but often many more. In severe cases, patients may not recognize that the obsessions or compulsions are excessive and therefore have
OCD “with poor insight.” Initially, onset of
OCD symptoms usually occurs in the 20s, with a waxing and waning course. The onset of primary
OCD after the age of 35 is unusual and should prompt a complete neurologic evaluation. Comorbid tic disorders and compulsive skin picking and hair pulling (trichotillomania) are common in
OCD. These comorbid disorders may be the impetus for treatment. The physical stigmata of compulsions (e.g., raw and rough hands from excessive handwashing or hairless patches from hair pulling) may be evident on physical examination.
Posttraumatic Stress Disorder Exposure to a
highly traumatic event as a victim or witness in which life or injury was threatened is the situational trigger for posttraumatic stress disorder (
PTSD). This traumatic event is followed by symptoms of
re-experiences (flashbacks, nightmares, intrusive memories of the event),
avoidance/numbing (avoiding conversations, activities, and people associated with the event or that may trigger experiences of the event), and
increased autonomic arousal (hypervigilance, restlessness, exaggerated startle). If symptoms resolve within 1 month following the traumatic event, the diagnosis of acute stress disorder (
ASD) is made. Patients with symptoms lasting
greater than 1 month are diagnosed with
PTSD.
Groups at risk for
PTSD include combat veterans, natural disaster survivors, terrorist attack survivors, victims of childhood abuse, and victims of sexual or physical trauma.
Sometimes the primary care provider will be aware that a traumatic event has occurred, for example, a recent motor vehicle accident or gunshot wound. However, at other times, patients may present with only nonspecific avoidance behaviors and physical symptoms and not mention the traumatic event. Reasons may include not recognizing the impact of the event and fear that they will be seen as damaged or unstable. Therefore, screening patients with these nonspecific symptoms for a recent traumatic event is important.
PTSD is more likely to develop in patients with direct exposure to interpersonal trauma (e.g., rape) than indirect exposure and events such as natural disasters.
Other Clinically Relevant Anxiety Disorders
Adjustment Disorder with Anxiety Adjustment disorder with anxiety is commonly seen in the primary care setting. The hallmark of this
disorder is the
close temporal relationship of the onset of anxiety symptoms to
a stressful event, usually within days, and
resolution within 6 months of the termination of the stressor. Although symptoms may initially be quite intense, they are generally short-lived and diminish with the passage of time. There is symptom overlap with other disorders, but the duration and threshold specifiers distinguish adjustment disorder from other anxiety disorders. For example,
GAD requires symptoms to be present for at least 6 months and
PTSD and
ASD require the stressor to be extreme in nature. Unlike the other anxiety disorders, there is an expectation of good outcome with adjustment disorder once the offending stressor is removed. If the stressor persists, anxiety symptoms will be present in a more attenuated form. Treatment is supportive to help the patient resolve or manage the stressor. Pharmacotherapy with antidepressants and benzodiazepines is sometimes utilized, but there is little evidence to support this practice.
Anxiety Disorder Not Otherwise Specified Many patients in the primary care setting will not initially fit neatly into any of the major anxiety disorders noted above. Assuming the symptoms are causing significant clinical distress, a diagnosis of anxiety disorder not otherwise specified (
NOS) can be made. As patients become more comfortable and provide additional history, a specific diagnosis may be more apparent. At other times, a more specific diagnosis is not possible due to confounding general medical conditions. For example, in the case of
PD, a reasonable initial diagnosis may be anxiety disorder
NOS, to rule out anxiety disorder due to a general medical condition versus panic disorder. Finally, some patients may never manifest the required number of diagnostic criteria for a specific anxiety disorder, yet the symptoms are clinically significant. For example,
PTSD without autonomic hyperarousability may be diagnosed as anxiety disorder
NOS.