Anxiety Disorders

Anxiety Disorders

*Please note that the below information is intended to provide generalized information to help increase awareness and education about CBT-I. It should not be used as a substitute for thorough, individualized assessment, diagnosis, or treatment by a licensed physician or other professional. Your provider may recommend an approach that differs from the below based on your individualized assessed needs.

Key points

  • Anxiety disorders are the most common psychiatric condition seen in primary care.
  • Patients may present with unexplained symptoms and be unaware of anxiety as the source.
  • Anxiety disorders often go undetected and untreated.
  • Screening tools such as the GAD-7 can help.
  • Effective treatments are available, though underutilized, prolonging patient suffering.
  • Research indicates that patient outcomes are optimal with combined pharmacologic and psychotherapy interventions.


  1. Define anxiety
  2. Recognize common emotional, physical and cognitive signs and symptoms
  3. Identify causes
  4. Cite the prevalence
  5. Differentiate normal anxiety from disorder
  6. Understand types of anxiety disorders
  7. Recognize options for treatment
  8. Understand ways to support patients and loved ones

What is Anxiety?

  • Apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension.
  • The focus of anticipated danger may be internal (i.e., having a heart attack) or external (i.e., being humiliated in public).

Emotional Symptoms

  • Feelings of apprehension or dread
  • Feeling tense
  • Feeling jumpy or “on edge”
  • Worrying excessively
  • Restlessness
  • Inability to relax
  • Irritability
  • Expecting the worst and being hypervigilant for signs of danger

Physical Symptoms

  • Pounding or racing heart
  • Shortness of breath
  • Sweating
  • Tremors
  • Headaches
  • Fatigue
  • Insomnia
  • Upset stomach
  • Diarrhea

Anxious Thinking

  • Poor concentration
  • Mind frequently goes blank
  • Overestimate risk or danger
  • Underestimate ability to cope
  • Catastrophic thinking-anticipating the worst-case scenario
  • Jumping to conclusions – negative assumptions without supporting evidence
  • Mind reading – presuming negative judgment or reaction by others
  • Personalization – interpreting events and reactions as due to self
  • Negative filter – magnifying negative details and filtering out positive
  • Should statements – thoughts imbued with rigid, unrealistic expectations
  • Emotional reasoning – equating emotions as reflecting truth absent evidence (i.e., feeling helpless is viewed as being helpless).

Causes of Anxiety

  1. Genetics – anxiety disorders tend to run in families; anxious predisposition/temperament.
  2. Life events – including a stressful or traumatic event such as abuse, death of a loved one, exposure to violence, prolonged illness, and poor overall health.
  3. Environmental factors – including difficult family relationships, lack of adequate social supports, and low-income status.


An estimated 40 million adults in the US, which is about 18% of the population, have an anxiety disorder. Among youth, approximately 8% are affected. Most individuals develop anxiety disorders before the age of 21, and these conditions often persist if left untreated. Women are 60% more likely to be diagnosed with anxiety disorders compared to men, resulting in an approximate 2:1 ratio between women and men diagnosed with anxiety disorders.

From Normal to Disorder

Anxiety is a universal experience, with everyone encountering some level of it in their lives. Mild anxiety can even serve as a motivating factor for certain behaviors. However, when anxiety reaches the level of a disorder, it is characterized by significant distress and/or impairment in functioning. Unlike transient or stress-induced anxiety, anxiety disorders are marked by their excessive or persistent nature, which interferes significantly with daily life. Associated problems with anxiety disorders include elevated divorce rates, higher rates of unemployment, a diminished sense of well-being, and increased reliance on assistance.


We are naturally inclined to avoid situations that trigger fear or anxiety. In the case of anxiety disorders, individuals often engage in safety behaviors during anxiety-provoking situations. These behaviors offer temporary relief from anxiety but do not address the underlying issues. Paradoxically, avoidance of anxiety-provoking situations only serves to perpetuate and maintain anxiety in the long term. By avoiding challenging situations, individuals miss opportunities for growth and learning how to cope effectively with their anxiety, ultimately leading to its persistence.

Fight, Flight, or Freeze Response

The body’s acute stress response is a built-in physiological mechanism designed to react swiftly to perceived threats to survival. When faced with such threats, the sympathetic nervous system is activated, preparing the body for intense physical activity in preparation for fight or flight. However, the amygdala, a key structure in the brain’s limbic system responsible for processing emotions, cannot distinguish between a real threat and a perceived one. As a result, anxiety can produce “false alarms,” triggering the stress response even in situations where there is no actual danger present. This phenomenon can lead to heightened feelings of anxiety and physiological arousal, despite the absence of a genuine threat, creating a cycle of perceived danger and heightened stress responses.


To effectively diagnose an anxiety disorder, healthcare providers follow a systematic approach. They first rule out potential causes stemming from general medical conditions or medication/substance use. Next, they assess whether symptoms could be better explained by another mental disorder. A thorough physical examination conducted by a physician helps eliminate any underlying medical conditions contributing to anxiety symptoms. Finally, diagnostic evaluation by a mental health professional, such as a psychologist or psychiatrist, allows for a comprehensive assessment of the individual’s symptoms, history, and overall mental health status, facilitating an accurate diagnosis and appropriate treatment plan.

GAD-7 scoring

  • 0-4 Minimal anxiety
  • 5-9 Mild anxiety
  • 10-14 Moderate anxiety
  • 15-21 Severe anxiety

Related conditions

90% of individuals with GAD have a co-morbid psychiatric diagnosis including the below:

  • Another anxiety disorder
  • Depression
  • Substance use disorders
  • ADHD
  • Eating disorders
  • Sleep problems
  • Increased risk of suicide

Separation Anxiety Disorder

  • Fear or anxiety about separation from attachment figures to a degree that is developmentally inappropriate.
  • Persistent fear or anxiety about harm coming to attachment figure and events that could lead to loss of or separation from attachment figures.
  • Persistent reluctance or refusal to go away from attachment figure.
  • Repeated nightmares with separation themes.
  • Physical symptoms of distress (headaches, stomachaches) during or in anticipation of separation.

Selective Mutism

Selective mutism is characterized by a consistent failure to speak in specific social situations where there is an expectation to speak, despite speaking in other contexts. This inability to speak can have significant consequences on academic or occupational achievement, as well as interfere with normal social communication. Individuals with selective mutism may experience intense anxiety or fear in certain situations, leading to an inability to verbalize thoughts or feelings. This condition can greatly impact daily functioning and may require intervention from mental health professionals to address underlying anxiety and develop strategies for effective communication.

Specific Phobia

Phobias involve intense fear or avoidance of specific objects or situations, often out of proportion to the actual risk. This anxiety can significantly impact daily life and may require therapy to manage.


  1. Animal (spiders, dogs)
  2. Natural environment (heights, storms, water)
  3. Blood-injection-injury (needles, invasive medical procedures)
  4. Situational (airplanes, elevators, enclosed spaces)
  5. Other (situations that may lead to choking or vomiting, costumed characters, loud sounds)

Social Anxiety Disorder

  • Fear, anxiety, or avoidance of social interactions or situations that involve possible scrutiny.
  • Include situations such as meeting unfamiliar people, eating or drinking in front of others, and performances.
  • Cognitive ideation of being negatively evaluated, embarrassed, humiliated, rejected, or offending others.

Panic Attack

  • Palpitations, pounding heart
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, light-headed, or faint
  • Chills or heat sensations
  • Paresthesias (numbness or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or “going crazy”
  • Fear of dying

Panic Disorder

Panic disorder involves recurrent, unexpected panic attacks, marked by intense fear and physical symptoms. Individuals often worry about future attacks and may develop avoidance behaviors. Treatment includes therapy and medication to manage symptoms and prevent future episodes.


Marked fear and anxiety about two or more of the following situations:

  1. Using public transportation (autos, buses, trains, ships, planes)
  2. Being in open spaces (parking lots, marketplaces, bridges)
  3. Being in enclosed spaces (shops, theaters, cinemas)
  4. Standing in line or being in a crowd
  5. Being outside of the home alone

Fear is due to thoughts that escape may be difficult or help may not be available in the event of panic-like symptoms. The situation almost always induces fear or anxiety and is avoided or requires a companion’s presence.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by persistent, excessive worry about various events and activities. Individuals with GAD often find it challenging to control their worry, which can significantly impact their daily functioning. Diagnosis typically requires the presence of three or more of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. These symptoms can cause considerable distress and impairment in various areas of life. Treatment for GAD often involves a combination of therapy, medication, and lifestyle changes to help manage symptoms and improve quality of life.


  • Medication (antianxiety and antidepressants)
  • Psychotherapy including cognitive-behavioral therapy (CBT)
  • Exposure and response prevention (phobias, social anxiety)
  • Stress management, relaxation and coping skills training
  • Yoga and aerobic exercise
  • Dietary changes (i.e., eliminate caffeine)
  • Self-management strategies and psychoeducation


Separated into two categories:

  1. Prevention of future anxiety –SSRI, SNRI; often take 4-8 weeks to show effectiveness. Shorter trials may lead to erroneous conclusion of inefficacy. These are considered the mainstay of pharmacotherapy.
  2. Treatment of acute anxiety – anxiolytics (benzodiazepines and non-benzodiazepines); treatment should generally be limited in duration and d/c once antidepressants take effect and the patient is able to engage in other forms of treatment (i.e., psychotherapy). Benzodiazepine risks include rebound anxiety when effects wane, and physiologic dependence.  Alternatives include hydroxyzine, propranolol, gabapentin (without abuse potential).


  • CBT involves identification of maladaptive automatic thoughts and behaviors and cognitive restructuring through therapeutic exercises.
  • While pharmacotherapy and psychotherapy have shown individual effectiveness, combined treatment clearly shows superior results compared to either treatment alone.
  • Breathing exercises, progressive muscle relaxation, exercise, mindfulness-based meditation are useful adjunctive therapies.
  • Cognitive restructuring

Specific Treatments and Recommendations

Generalized Anxiety Disorder

  • Generalized nature of symptoms require use of medication aimed at prevention.
  • SSRI/SNRI mainstay of therapy.
  • Anxiolytics have limited overall utility. Long-acting benzodiazepines such as clonazepam offer some benefit, though still fail to prevent future anxiety once worn off.
  • Augmentation with agents such as mirtazapine, buspirone, atypical antipsychotics have been effective (usually best done with psychiatric consult).
  • Psychotherapy is very effective for GAD.

Panic disorder

  • Treatment centers on prevention of panic attacks and reducing anxiety about future attacks.
  • SSRI/SNRI’s are effective in preventing attacks and reducing overall anxiety.
  • Benzodiazepines may help abort an impending attack that lasts longer than 20 minutes, although use may worsen psychotherapy response or outcome.
  • Longer-acting benzodiazepines such as clonazepam may reduce overall anxiety that can trigger attacks, though use should be reserved for patients who cannot function without them, or who cannot tolerate serotonergic agents.
  • Psychotherapy for Panic Disorder is at least as effective, and at times superior, to medication.
  • CBT is the most studied and validated.

Social anxiety disorder

  • SSRI/SNRI’s are first-line agents.
  • Limited use for anxiolytics except for specific anxiety-provoking situations (i.e., public speaking) that acutely worsens symptoms. Propranolol may be used in low doses effectively.
  • CBT focuses on exposure to anxiety-provoking situations to demonstrate that resultant anxiety is tolerable and not dangerous. Systematic desensitization occurs over time with repeated exposure to the feared stimulus, lessening distress and avoidance behaviors. Combined with cognitive restructuring and challenging anxious thinking distortions, this is the most effective psychotherapy available for Social Anxiety Disorder.

Helping a Loved One with Anxiety

  • Learn about their triggers, stressors and symptoms.
  • Communicate honestly and kindly.
  • Ask rather than assume.
  • Allow time for recovery.
  • Recognize and find positives in steps towards recovery.
  • Respond calmly and in a validating manner.
  • Encourage them to seek out therapy.


Becoming an expert in managing anxiety involves understanding triggers and stressors and planning accordingly. Individuals should partner with their healthcare providers to develop effective coping strategies and treatment plans. Prioritizing overall health through lifestyle changes such as regular exercise and adequate sleep can also help manage anxiety. Avoiding substances like caffeine, drugs, and alcohol, which can exacerbate symptoms, is essential. Seeking support from friends, family, and therapy can provide additional resources and tools for managing anxiety effectively.

Many patients initially present with anxiety disorders in primary care settings, providing an important opportunity for detection and treatment initiation by primary care providers. Effective detection of anxiety disorders can be achieved through screening tools, allowing for early intervention and improved outcomes. Combining therapies, such as psychotherapy and psychopharmacology, has been shown to yield the best results for most patients with anxiety disorders. This comprehensive approach addresses both the psychological and physiological aspects of anxiety, leading to better symptom management and overall well-being.


  • DSM-V
  • Combs, H. & Markman, J.  (2014). Anxiety Disorders in Primary Care. Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington.