YUJUAN CHOY, M.D.

What are Symptoms of Anxiety and Panic?

Anxiety is a very uncomfortable emotional state in which there is a feeling of apprehension and nervousness, along with many physical symptoms of arousal.  These symptoms may include sweating, trembling, heart palpitations, pounding or racing heart, shortness of breath or feelings of dizziness. A panic attack is a period of anxiety in which many of these symptoms suddenly occur in a rush, and there is a fear that something terrible is happening, like the person is going to die, have a heart attack, or go crazy and lose control.

Anxiety or panic attacks can be a symptom of certain medical conditions.  Before attributing anxiety symptoms to an emotional or psychiatric problem, it is important to first check with a medical doctor to eliminate any medical causes of anxiety such as a cardiac or respiratory condition or hormonal problems like thyroid disease.  In addition, some medications and substances like caffeine, marijuana, stimulants (e.g. cocaine, methamphetamines) and other recreational drugs can cause anxiety.  This list is not comprehensive, so you should discuss with your doctor about other possible causes for your anxiety.  Once a medical cause is ruled out, and you are found to be physically healthy, than you can consider alternative explanations for the anxiety.


What is Social Anxiety Disorder (or Social Phobia)?

What is Generalized Anxiety Disorder (GAD)?

What is Panic Disorder?

What is Post-traumatic Stress Disorder (PTSD)?

What is Obsessive Compulsive Disorder (OCD)?


What is Social Anxiety Disorder (or Social Phobia)?

Having some anxiety in certain social situations, particularly during novel or important events is a normal part of life. For example, it is not uncommon for people to feel nervous during an exam (e.g. a final, GRE, LSAT), attending a wedding, going on a job interview or on a first date. In fact, a modest level of anxiety may be optimal for performance.  People with social anxiety disorder (also known as social phobia) experience more than the normal range of anxiety in social situations. Anxiety can be limited to just one type of situation (e.g. performance anxiety) or experienced in many different social settings.

People with social anxiety disorder are concerned about what others think of them in social or performance situations. The common situations include:

  • Causal conversations
  • Public speaking
  • Meeting new people
  • Dating
  • Being in center of attention
  • Attending social gatherings
  • Speaking up in class or in work meetings
  • Speaking to authority figures
  • Making a request
  • Being assertive
  • Eating, drinking, writing or working in front of others
  • Taking on the phone

They worry that they will act or behave in a way that will be embarrassing or humiliating.  Many are also concerned that others will notice their physical symptoms of anxiety, such as blushing, trembling, sweating, and as a result, will be embarrassed or look like an "idiot" in front of people.  Because of these fears, they often go to great lengths to avoid these situations or experience severe distress (sometimes panic attacks) if they can't avoid them. They realize that other people are not as afraid of these situations and that their anxiety may be excessive.  Social anxiety disorder can interfere with life in many ways, including limiting a person's social network, preventing the person from finishing school or doing well at work.  Fear and avoidance usually results in many lost opportunities, such as meeting a potential life partner, making new friends, or getting a job promotion.

Social anxiety disorder is one of the most common psychiatric disorders in the U.S., affecting 12.1% of the U.S. population.  It is a chronic condition that typically begins in adolescence or early adulthood.  Many people do not come for treatment, and people seeking treatment have lived with the problem for 10 or more years.  Left untreated, social anxiety disorder can be a risk factor for other anxiety problems, depression or alcohol abuse.

There are very effective treatments for social anxiety disorder, including   cognitive behavioral therapy (CBT) and/or medication.  CBT is a well-studied, empirically supported, and a validated form of psychotherapy for social anxiety disorder.  You should discuss with your doctor which type of treatment is appropriate for you.


References

Kessler RC, P Berglund, O Demler, R Jin, KR Merikangas, EE Walters. (2005) Lifetime prevalence and age-of-onset distributions for DSM-IV disorders in the National Comorbidity Survey Replication.  Archives of General Psychiatry. 62: 593-602.

Schneier, FR (2006)  Social Anxiety Disorder.  The New England Journal of Medicine. 355 (10): 1029-1036.


What is Generalized Anxiety Disorder (GAD)?

It is natural to worry about things, particularly when the events are important, such as passing an exam, undergoing a diagnostic test for a serious illness, making sure that a family member is safe, or being prepared for a job promotion or a new baby on the way.  Worrying about important events, both good and bad, is a natural adaptive response, and can help motivate us to perform better, prepare us for disaster situations. 

People with GAD experience more than the normal range of worries about many real life situations, such as their or their family's health, work, finance, family/social relationships and daily activities.  They worry more than they want to and cannot control these thoughts.  Excessive worrying becomes a problem when it leads to severe anxiety symptoms or interferes with daily activities, work productivity or relationships.  People with GAD typically report:

  • Feeling restless, jittery, keyed-up, and on edge all the time
  • Having problems sleeping at night
  • Feeling tired and fatigued during the day
  • Feeling burnt-out or emotionally drained
  • Getting irritable with friends, family or colleagues
  • Having problems concentrating or focusing at work

GAD can be a very distressing and disabling disorder.  It is a chronic condition that affects about 5.7% of the U.S. population.  GAD interferes wtih the ability to handle stress and solve problems.  For example, small chores that used to be easy can become overwhelming at times of stress. 

There are very effective treatments for GAD, including cognitive behavioral therapy (CBT) and/or medication.  CBT is a well-studied, empirically supported, and a validated form of psychotherapy for GAD.  You should discuss with your doctor which type of treatment is appropriate for you.

References

Kessler RC, P Berglund, O Demler, R Jin, KR Merikangas, EE Walters. (2005) Lifetime prevalence and age-of-onset distributions for DSM-IV disorders in the National Comorbidity Survey Replication.  Archives of General Psychiatry. 62: 593-602.

Stein DJ and E Hollander, editors. 2002. Textbook of Anxiety Disorders. Washington, D.C.: The American Psychiatric Publishing.


What is Panic Disorder?

People suffering from panic disorder have frequent, recurrent, and unexpected panic attacks.  Panic attacks are sudden feelings of being frightened, terrified, accompanied by a rush of physical symptoms, including sweating, trembling, pounding or racing heart, shortness of breath or feelings of dizziness.  Panic attacks are very scary experiences because during the attack, people feel as if they are going to die, something really bad is happening, or they are going crazy or lose control.

Panic attacks can occur in certain medical conditions.  Before attributing it to an emotional or psychiatric problem, it is important to first check with a medical doctor to eliminate any medical causes of panic attacks such as a cardica or respiratory condition or hormonal problems like thyroid disease.  In addition, some medications and substances like caffeine, marijuana, stimulants and other recreational drugs (e.g. cocaine, methamphetamines) can cause panic attacks. This list is not comprehensive, so you should discuss with your doctor other possible causes for your panic attack.  Once a medical cause is ruled out, and you are found to be physically healthy, than you can consider alternative explanations for the panic attack.

People with panic disorder worry almost daily that they will have another attack and are in a persistent state of anxiety anticipating the next attack. They visit ERs and doctors frequently, and even after reassurance, they feel they have some physical problem that their doctors have not discovered because the panic attacks would recur. In addition, people with panic disorder often change their life style or behavior in some way so as to limit the likelihood of having another panic attack. For example, if the person had an attack while driving, then they will not drive alone or avoid driving all together. People can become so frightened by an attack that they will try to avoid any situation that they think will bring on another attack or situations where they cannot escape or get help if an attack occurs. This is called "agoraphobia."  Some of the situations typically avoided include:

  • Elevators
  • Restaurants
  • Theatres
  • Classrooms
  • Supermarkets or shopping malls
  • Parking garages
  • Riding in trains, buses, subways, airplanes
  • Standing in a line
  • Being far away from home
  • Staying at home alone
  • Walking alone in the street

Panic disorder is a chronic illness with a fluctuating course; symptoms can wax and wane over time. It affects about 4.7% of the U.S. population. Panic disorder is twice as common in women as in men. It typically begins in late adolescence or early adulthood. Left untreated, panic disorder can be debilitating and can prevent someone from functionng in daily life. It can sometimes leads to suicide, and is associated with other psychiatric illness such as other anxiety disorders, depression and alcohol abuse.

There are very effective treatments for panic disorder, including cognitive behavioral therapy (CBT) and/or medication.  CBT is the most widely studied, empirically supported, and a validated form of psychotherapy for panic disorder.  You should discuss with your doctor which type of treatment is appropriate for you.

References

Kessler RC, P Berglund, O Demler, R Jin, KR Merikangas, EE Walters. (2005) Lifetime prevalence and age-of-onset distributions for DSM-IV disorders in the National Comorbidity Survey Replication.  Archives of General Psychiatry. 62: 593-602.

Roy-Byrne PP, Craske MG, Stein MB. (2006). Panic Disorder. Lancet. 16(368): 1023-1032.


What is Posttraumatic Stress Disorder (PTSD)?

Exposure to a life-threatening event, such as in combat, natural disaster, terrorist attack, serious motor vehicle accident, victim of a violent crime, physical assault or sexual assault, or witnessing a death, may cause emotional problems. While most people who experience or witnessed such events recover and feel much better over time, some people develop PTSD and continue to be affected many months or even years following the event. 

People with PTSD frequently re-live the event through flashbacks and nightmares, and try to avoid any feelings, thoughts, memories, or conversations that remind them of the event. Relaxing, concentrating or sleeping may become difficult. They often feel detached or estranged from loved ones. They may become fearful of going to certain places or enter certain situations associated with the trauma. They may start to believe that people in general are not trustworthy or that they are incompetent and weak since they are experiencing symptoms. 

Some symptoms of PDSD include:

  • Anxiety, fear or anger
  • Having intrusive images, thoughts or memories
  • Feeling jumpy and hyperalert
  • Becoming impatinet and irritable with loved ones
  • Having problems sleeping or concentrating
  • Feeling a lost of control
  • Feelings of depressed mood, lost of interest
  • Shame/guilt

PTSD affects about 6.8% of the U.S. population.  It is more common in women, and symptoms tend to be more persistent in women than in men. Civilian related traumas, such as victims of crimes, motor vehicle accidents, sexual assaults, account for the majority of PTSD in the U.S., although combat-related traumas account for a large proportion of PTSD in men.

Both medication and psychotherapy are effective treatments for PTSD.  Studies showed that exposure therapy, a form of behavioral therapy, is the most well-supported treatment for PTSD.  One form of exposure therapy is called Prolonged Exposure.  Prolonged Exposure is a well-established treatment program that has been developed and validated for the treatment of PTSD.  Other forms of therapy have also been shown to be beneficial, including cognitive therapy, stress inoculation training, EMDR, and interpersonal psychotherapy.   You should discuss with your doctor which type of treatment is appropriate for you.

References

Kessler RC, P Berglund, O Demler, R Jin, KR Merikangas, EE Walters. (2005) Lifetime prevalence and age-of-onset distributions for DSM-IV disorders in the National Comorbidity Survey Replication.  Archives of General Psychiatry. 62: 593-602.

Nemeroff CB, JD Bremmer, EB Foa, HS Mayberg, CS North, MB Stein. 2006. Posttraumatic Stress Disorder: a state-of-the-science review. Journal of Psychiatric Research. 40(1): 1-21.


What is Obsessive Compulsive Disorder (OCD)?

It is common to be concerned with things that keep you safe and healthy, such as washing your hands after using the bathroom or checking to make sure the door is locked when leaving the house.  Normal people also experience unwanted thoughts or images at times (e.g. thinking of driving of the road while driving), but they are not bothered by these thoughts. 

People with OCD have either obsessions and/or compulsions that are persistent, time-consuming, and cause a lot of distress or significantly interfere with daily routines, work, school or relationships. 

Obsessions are recurrent, unwanted and intrusive thoughts, ideas, impulses or images that cause a lot of distress.  The person is unable to control these thoughts, can't get them out of their heads, and attempt to ignore, suppress or get rid of these thougths without success.  Typical types of obsessions include:

  • Fear of bodily secretions like sweat, saliva, urine, etc.
  • Fear of contamination with dirt or germs from the environment (e.g. door knobs, public bathrooms)
  • Fear that they may harm themselves or others (e.g. stab self or others if see a knife, but not suicidal or homicidal thoughts)
  • Having violent or horrific images (e.g. multilated bodies)
  • Fear that they will act on unwanted impulses (e.g. hit a friend)
  • Having unwanted sexual thoughts or images
  • Having fears of throwing away things of no monetary or sentimental value
  • Having excessive unwanted religious thoughts'
  • Need for things to be symmetrical or exact

Compulsions are repetitive behaviors or mental rituals that the person feels driven to perform in response to an obsession or some rigid rule in order to ease their anxiety.  The following are typical compulsions:

  • Excessive handwashing or bathing
  • Feeling need to follow a ritual in dressing or washing
  • Checking things frequently (e.g. doors, windows, light switch, oven, appliances)
  • Checking that they did not or willnot harm themselves or others
  • Checking that they did not make a mistake
  • Needing to arrange things in a particular way
  • Needing to repeat certain routine activities
  • Counting to a certain number, counting objects, letters, etc.
  • Needing to collect things of no monetary or sentimental value (e.g. junkmail, old newspapers)
  • Having a mental ritual like saying specific words, special prayers, making lists

OCD is a very debilitating disorder that affects about 1.6% of the U.S. population. It affects women and men equally, and typically begins in early adulthood, peaking during adolescence in males and in the 20s in females. OCD is a chronic illness that waxes and wanes in severity over time, and is often worsened at times of stress. Left untreated, OCD can substantially interfere with a person's normal routine, schoolwork, job, family or social activities.

Both medication and psychotherapy are effective treatments.  Empirically supported treatments include medication and/or a form of behavioral therapy called prolonged exposure and response prevention (EXRP).

References

Goodman WK, LH Price, SA Rasmussen, C Mazure, RL Fleischmann, CL Hill, GR Heninger, DS Charney. (1989).  The Yale-Brown Obsessive Compulsive Scale: 1. Development, use and reliability. Archives of General Psychiatry. 46: 1006-1011.

McGuinn LK and WC Sanderson. (1999). Treatment of Obsessive Compulsive Disorder. NJ: Jason Aronson. Inc.


Other Educational Resources

You can learn more about anxiety disorders from the following organizations and websites: