6 General adult psychiatry6.1 Psychiatric disorders in adulthood
6.1.3 Anxiety disorders
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Written by Resident Doctor Committee · Published
Classification
Anxiety disorders are excessive fear or worry with avoidance and impaired function. ICD-11 places obsessive-compulsive and trauma-related disorders in separate groups, because their defining features and treatments differ.
Disorder (ICD-11 code) | Core picture | Told apart from |
|---|---|---|
Generalised anxiety disorder, GAD (6B00) | Persistent, hard-to-control worry across several life domains | Ordinary, manageable worry |
Panic disorder (6B01) | Repeated unexpected attacks, then concern or changed behaviour | An isolated panic attack |
Agoraphobia (6B02) | Fear of situations where escape or help seems difficult | Fear defined only by panic history; it can occur without panic disorder |
Specific phobia (6B03) | Excessive fear tied to one object or situation | Proportionate fear |
Social anxiety disorder (6B04) | Fear of scrutiny or negative evaluation | Shyness |
Symptoms of anxiety
Somatic symptoms come from sympathetic arousal: palpitations, fine tremor, sweating, breathlessness and gastrointestinal discomfort. They are distinct from the psychological, cognitive and dissociative features.
Globus is a feeling of a lump or tightness in the throat without true difficulty swallowing; it is felt between meals and eased by eating.
Epidemiology
Phobias were the commonest anxiety disorders in the US Epidemiologic Catchment Area community survey, and specific phobia has the highest population prevalence.
Panic disorder, obsessive-compulsive disorder (OCD) and GAD are more prominent in clinics, because help-seeking, not occurrence, drives attendance.
Most people with specific phobia never seek or receive treatment, since avoiding the feared stimulus keeps distress and impairment low.
The Adult Psychiatric Morbidity Survey 2014 gave past-week rates of 5.9% for GAD, 2.4% for phobias and 0.6% for panic disorder.
Specific phobia usually starts in childhood, social anxiety in adolescence, and panic disorder and agoraphobia in early adulthood; GAD onset varies, and courses fluctuate over years.
Sex ratios
Disorder | Women to men |
|---|---|
GAD, post-traumatic stress disorder (PTSD), specific phobia overall | About 2:1 |
Panic disorder | About 2:1, widening to about 3:1 with agoraphobic avoidance |
Blood-injection-injury phobia | About equal |
Social anxiety disorder | Most nearly equal: small female excess in the community; men equal or over-represented in clinics |
Excoriation disorder | About 3:1 (three quarters or more are women) |
Trichotillomania | About 10:1 in adults, the largest female excess; children more equally affected |
Comorbidity
Depression is the commonest comorbidity of GAD: about 62% have a lifetime major depressive episode, through shared vulnerability and overlapping criteria (concentration, restlessness, sleep, fatigue).
Panic disorder co-occurs more often than chance with respiratory, gastrointestinal, cardiovascular and neuro-otological illnesses.
Other anxiety disorders and substance use often coexist; people use alcohol or sedatives to manage symptoms, which later worsens them.
Aetiology
Heritability is about 30 to 40%, with liability shared with depression and neuroticism.
Behavioural inhibition in childhood raises later risk, especially of social anxiety, but does not determine it.
Mowrer's two-factor model holds that fear is acquired by conditioning and kept going by avoidance, which is negatively reinforced because it relieves anxiety.
Avoidance also stops the person learning that the feared outcome may not happen.
Seligman's preparedness theory proposes that evolution makes some fears, such as of snakes or heights, easier to acquire.
Clark's panic model holds that people misread bodily sensations catastrophically (palpitations as a heart attack), which raises arousal and confirms the belief.
Safety behaviours, such as gripping a rail, preserve the belief that catastrophe was only narrowly prevented.
Clinical pictures
Generalised anxiety disorder
GAD is persistent, excessive, free-floating worry about several everyday matters on most days for months, without a single trigger.
Motor tension or restlessness, autonomic arousal, irritability and poor concentration accompany the worry.
Its sleep disturbance is insomnia, not hypersomnia.
Panic disorder and agoraphobia
Panic attacks are abrupt and peak within minutes.
Panic disorder requires at least some unexpected attacks with no identifiable cue, followed by dread of the next one; attacks can arise from sleep.
Attacks cued only by a feared situation do not make panic disorder.
Attacks that began unprovoked and later became loosely linked to some places remain panic disorder, provided most are still unprompted and the person neither avoids nor dreads those places.
Agoraphobia is fear of several situations where escape would be hard or help unavailable, which are avoided or endured only with a companion.
In agoraphobia, panic occurs only in those places, no single trauma lies behind it, and severe cases cannot leave home.
Social anxiety disorder and specific phobia
Social anxiety disorder is fear of scrutiny and negative judgement across several social situations: performing, eating or drinking while watched, and ordinary socialising.
It brings avoidance, blushing, trembling and palpitations.
Panic attacks cued only by feared scrutiny belong to social anxiety disorder, not panic disorder: the trigger and content of the fear decide the diagnosis.
Ask about safety behaviours as well as avoidance: someone may attend a party but avoid eye contact and rehearse every sentence.
Taijin kyofusho is a cultural form in which the fear is of offending others through one's appearance or odour.
Specific phobia is marked fear and avoidance confined to one object or situation, with normal functioning elsewhere.
Blood-injection-injury phobia has a diphasic physiological response that can end in vasovagal fainting, which applied tension helps.
Differential diagnosis
Cause | Examples | Pointers against primary anxiety |
|---|---|---|
Endocrine | Thyrotoxicosis, phaeochromocytoma, hypoglycaemia | Systemic signs, biochemical change, episodic hypertension |
Cardiac | Paroxysmal supraventricular tachycardia | Abrupt rhythm change on electrocardiogram |
Respiratory | Asthma, chronic obstructive pulmonary disease | Wheeze, hypoxia |
Neurological | Temporal lobe epilepsy | Brief stereotyped episodes, automatisms, altered awareness |
Drugs | Caffeine, stimulants, cocaine, salbutamol, excess thyroid replacement | Timing against exposure or dose |
Withdrawal | Alcohol, benzodiazepines | Dependence history, tremor, timing |
Late or atypical first onset needs careful physical review, with tests chosen by the findings rather than repeated for unchanged symptoms.
Depression and psychosis can also produce anxiety and avoidance.
Anankastic personality disorder is perfectionism that stops tasks being finished, with rigid rules and reluctance to delegate since adolescence.
It differs from OCD because the person sees it as correct (ego-syntonic) and has no unwanted obsessions.
Reactions to stress
Diagnosis | Stressor | Timing | Picture |
|---|---|---|---|
Acute stress reaction (ICD-11) | Exceptional threat | Starts within minutes to hours; settles within hours to a few days | Dazed disorientation, narrowed attention, patchy memory for the event, autonomic arousal |
Adjustment disorder | Identifiable, non-catastrophic, such as redundancy | Starts within a month | Disproportionate, maladaptive reaction with rumination and impaired function |
PTSD | Extremely threatening or horrific | At least several weeks | See below |
Settling within days rules out PTSD, and symptoms lasting beyond two weeks rule out a transient acute stress reaction.
Adjustment disorder falls short of the stressor severity and symptom clusters that PTSD needs, and has no present-tense reliving.
Post-traumatic stress disorder
Diagnosis
The stressor must be extremely threatening or horrific; ICD-11 accepts direct or indirect exposure, such as learning of a loved one's sudden or violent death.
Onset is usually within three months, but delayed onset is possible; ICD-11 sets no fixed maximum interval.
System | Required elements |
|---|---|
ICD-11 PTSD | Three core elements: re-experiencing, avoidance, persistent sense of current threat |
ICD-11 complex PTSD | The three core elements plus three disturbances in self-organisation: affect dysregulation, negative self-concept, difficulty in relationships |
Hyperarousal shows as hypervigilance, exaggerated startle and insomnia, so reduced-arousal features such as hypersomnia do not fit PTSD.
Risk and course
Amygdala hyperactivity to trauma cues, the hub of conditioned fear, underlies the fear response and re-experiencing.
Childhood trauma raises vulnerability to PTSD and moderates its genetic risk.
Female sex is the most consistently replicated demographic pre-trauma risk factor.
Peritraumatic dissociation (detachment, unreality) predicts PTSD more strongly than visible distress or bodily arousal at the time.
Good social support favours recovery, whereas maladaptive coping and secondary stressors worsen outcome.
Chronic pain is strongly comorbid: a large share of people with PTSD have chronic pain, and a substantial share with chronic pain have PTSD.
Management (NICE 2018)
Situation | Approach |
|---|---|
Subthreshold, fading symptoms in the first month | Active monitoring with practical support and review planned within a month |
Clinically important symptoms in the first month (daily intrusions, avoidance, lost function) | Individual trauma-focused cognitive behavioural therapy (CBT), without waiting |
Established PTSD, more than a month after trauma | Individual trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) |
Person prefers drug treatment | Consider venlafaxine or a selective serotonin reuptake inhibitor (SSRI) such as sertraline |
Disabling hyperarousal or psychotic symptoms after both therapies and both drugs fail | Add an antipsychotic such as risperidone to continuing psychological treatment |
Trauma-focused therapies work on the trauma memory, its appraisals and avoidance; interpersonal psychotherapy is not first line.
Sertraline and paroxetine are UK-licensed for PTSD.
Tricyclics, monoamine oxidase inhibitors (MAOIs) and mirtazapine, from the superseded 2005 guidance, are not recommended.
Psychologically focused debriefing, single-session or multiple-session, is not advised to prevent or treat PTSD; a 2002 Cochrane review concluded that compulsory debriefing should stop.
Sleep problems in PTSD
Sleep disturbance in PTSD is heterogeneous, so treatment follows the cause.
Problem | Features | Treatment |
|---|---|---|
Replaying nightmares | The trauma recurs in dreams | Imagery rehearsal therapy: rewrite the nightmare and rehearse a less distressing version |
Persistent nightmares | Raised central noradrenergic activity | Prazosin, which blocks alpha-1 adrenoceptors |
Nightcap alcohol | Faster sleep onset, then a fragmented second half of the night with rebound arousal, rapid eye movement (REM) rebound and early waking | Reduce alcohol first |
Obstructive sleep apnoea, commoner in PTSD | Snoring, witnessed pauses, morning headaches, daytime sleepiness | Continuous positive airway pressure |
Chronic insomnia kept going by habits | Long hours in bed, clock-watching, naps | CBT for insomnia: stimulus control, sleep restriction, cognitive work |
Treatment of anxiety disorders
Principles
Explain the maintaining cycle in the person's own terms, and match intensity to impairment, preference and past response.
SSRIs and serotonin-noradrenaline reuptake inhibitors (SNRIs) may raise anxiety at first, so start cautiously; explain delayed benefit, adverse effects and withdrawal.
Monitor for agitation, akathisia and suicidal thinking, particularly in younger adults.
Benzodiazepines cause tolerance, dependence and withdrawal, so any use is short-term in clearly defined circumstances.
Reduce excess caffeine, tackle harmful alcohol use, support sleep and activity, and address social stressors.
GAD: NICE stepped care
Guided self-help, a low-intensity CBT-based intervention, sits at step 2 of NICE stepped care, before high-intensity therapy.
Psychological options for GAD are guided self-help, worry-focused CBT and applied relaxation.
Step 4 is specialist referral, considered for severe anxiety with marked functional impairment plus risk of self-harm or suicide, significant comorbidity, self-neglect, or inadequate response to step 3 treatment.
Drug treatment after a low-intensity psychological intervention follows this order:
Sertraline is the first SSRI, although its use in GAD is off-label.
An alternative SSRI or an SNRI such as venlafaxine follows.
Pregabalin is used when SSRIs and SNRIs are not tolerated; it is a controlled drug with risks of dependence and diversion, and needs respiratory and pregnancy review.
People under 30 starting an SSRI or SNRI for GAD are seen within a week and monitored weekly for suicidal thinking and self-harm through the first month.
Short-term benzodiazepine use in a crisis is accepted in GAD, unlike in panic disorder.
After response, continue medication for at least a year, then review gradual withdrawal.
Panic disorder
Mild panic disorder starts with low-intensity individual self-help in primary care.
CBT for panic uses interoceptive exposure and work on catastrophic interpretations.
When medication is chosen, the first drug is an SSRI licensed for panic disorder, such as escitalopram or sertraline.
With partial response to a well-tolerated SSRI below its maximum dose, optimise the dose before switching or adding, for example escitalopram increased to 20 mg daily.
Imipramine or clomipramine, neither UK-licensed for panic disorder, may be considered when an SSRI is unsuitable or has not helped after 12 weeks.
Benzodiazepines are not prescribed, because of a poorer long-term outcome; antipsychotics and sedating antihistamines are not recommended either.
After response, continue medication for at least six months.
Social anxiety disorder
Individual disorder-specific CBT (Clark and Wells, or Heimberg) is offered first, in preference to routine group CBT.
Guided self-help is used only when individual CBT is declined.
An SSRI (escitalopram or sertraline) is the first medicine for adults who decline or cannot engage with psychological therapy.
After no response to an SSRI and then venlafaxine, the next step is an MAOI (phenelzine or moclobemide).
A single oral beta blocker dose, such as propranolol, taken about an hour before a feared performance blunts autonomic signs in performance-only social anxiety.
Beta blockers have no place in generalised social anxiety or other anxiety disorders, do not change underlying beliefs, and need the usual contraindication checks.
Specific phobia, agoraphobia and OCD
Specific phobia is treated first with graded in vivo exposure, with no routine drug treatment.
Agoraphobia is treated with graded exposure and planned reduction of safety behaviours.
OCD is treated first with an SSRI, often at a higher dose and for a longer trial, around 12 weeks, than in depression.
Herbal remedies
Kava (Piper methysticum) has placebo-controlled, Cochrane-supported anxiolytic evidence, the strongest of any herbal remedy.
Kava is not recommended and was withdrawn or prohibited, including in the UK, because of hepatotoxicity.
Outcome and poor response
GAD and social anxiety in particular tend to persist or recur.
Anxiety that does not remit after adequately delivered, adhered-to treatment should prompt a search for a physical cause, a missed comorbidity or a wrong diagnosis, and a review of maintaining factors.
The GAD-7 measures change but cannot make a diagnosis on its own.
Track restored work, activity and relationships, because lower anxiety scores can coexist with substantial learned avoidance.