Anxiety disorders: the different types

There are different types of anxiety disorders. In this article, the DSM-IV criteria, characteristics, clinical picture and differential diagnosis are discussed for each disorder. Some anxiety disorders are similar. However, for the treatment of these anxiety disorders it is important that the correct diagnosis is made prior to treatment.

What are anxiety disorders?

Anxiety complaints are diagnosed using the DSM-IV, which includes manifest symptoms as criteria. The five axes of the DSM-IV;

1. Clinical syndromes
2. Developmental and personality disorders
3. Organic disorders and conditions
4. Severity of the psychosocial stress
5. The highest level of adaptive functioning during the past year

The DSM is classified by disorders, not by persons. As a person, you can have multiple disorders on the same or different axes. Anxiety disorders are included in Axis I, and are in turn subdivided. The different anxiety disorders will now be discussed one by one.

Panic disorder

DSM criteria

• The central feature of panic disorder is the panic attack (a discrete period of intense fear or tension, which often occurs unexpectedly). A panic attack occurs when at least one attack has four of the following symptoms within 10 minutes: Shortness of breath, dizziness, palpitations, trembling, sweating, feeling of choking, nausea, depersonalization, deafness, hot flushes, chest pain, fear of dying, fear of going crazy/losing control.
• If there are fewer than 4 symptoms, it is referred to as a ‘limited symptom attack’. One should not speak of a panic attack if an organic factor is the cause.
• DSM speaks of a panic disorder when 1 or more panic attacks occur, which are unexpected and not triggered by situations in which the attention of others is focused on the patient. Four panic attacks must have occurred within 4 weeks, or one or more attacks must be followed by a period of at least one month in which there is fear of another panic attack.
• In terms of severity, the DSM distinguishes between mild (at most 1 attack in the past month), moderate (in between) and severe (at least 8 attacks in the past month).

 

Clinical picture

Characteristics of a panic disorder:

• Unexpected/spontaneous nature of the panic attack. At first it is often unclear what causes the attack, but during the course of treatment, insight into the triggers of the attack often grows
• Physical symptoms are related to increased arousal.
• During an attack a tendency to escape; if this is not possible > restless walking/talking a lot.
• People with panic disorder are afraid of different things; that something is physically wrong, losing control/going crazy, a negative social evaluation
• Avoidance behavior; anxiety sensitivity and fear of fear (can lead to e.g. Agoraphobia)
• Anticipatory anxiety; fear between attacks that there will be another attack. Anticipatory anxiety is strongly colored by the threat of loss of control

The anticipatory fear due to the threat of loss of control has 4 themes:

1. Fear of somatic loss of control (body fails, e.g. myocardial infarction)
2. Fear of psychological loss of control (losing control over mental faculties, e.g. going crazy)
3. Fear of behavioral loss of control (total disinhibition, e.g. screaming)
4. Fear of loss of social control (embarrassment of symptoms, e.g. shaking)

 

Differential diagnostics

There are other disorders that can also cause episodes of anxiety, such as;

• Physical factors
• Hypochondria
• Substance abuse
• Generalized Anxiety Disorder (GAD)

 

Agoraphobia

DSM criteria

• Agoraphobia is the fear of being in places or situations from which it is difficult to escape, or where help is not available in the event of a panic attack.
• There are two types of agoraphobia; agoraphobia associated with panic disorder (avoidance associated with panic disorder), and agoraphobia (fear of sudden symptoms such as vomiting/derealization that may embarrass the patient)
• Degrees of agoraphobia; mild (some avoidance but fairly normal life), moderate (a restricted lifestyle) and severe (completely housebound).

 

Clinical picture

Characteristics of agoraphobia are:

1. Extensive avoidance behavior, not due to just ‘fear of the streets’ or fear of open spaces, but precisely fear of contained situations in which the person feels trapped (e.g. standing in line, public transport, etc.). So fear of fear, not of certain places.
2. Taking precautions so that patients can leave if they want to leave
3. Often more anxious when they are without company, but the opposite can also happen.
4. Fear of loss of control of a somatic nature and/or social nature.
5. Catastrophic thoughts, anxiety sensitivity and fear of fear

 

Differential diagnostics

Avoidance of situations can have several reasons other than agoraphobia;

• Depression
• Body Dysmorphic Disorder (BDD)
• Social phobia

 

Social phobia/anxiety disorder

DSM criteria

Social phobia is a marked and persistent fear of one or more situations that require social functioning or achievement and are exposed to strangers or to possible critical appraisal by others. The patient is convinced that his fear is exaggerated. The fear may not be related to another Axis I or Axis III disorder (e.g. fear of trembling in Parkinson’s).

Clinical picture

• Social anxiety is characterized by the fear of being the center of attention and being critically judged by others. This involves disabling cognitive processes, such as self-focused attention and the use of safety behavior; e.g. make-up that hides blushing, avoiding eye contact, etc. This often has the opposite effect, attracts attention).
• Everyone has some degree of social anxiety. Social phobia only occurs when fear in social situations hinders people’s social or occupational functioning.

In people with social phobia, a distinction is made into two components

1. (Inadequate) social skills; people with social phobia are often less socially skilled. The causal relationship here is not clear; Inadequate action can also be caused by fear.
2. Avoidance behavior; passive avoidance (safety behavior) and active avoidance (e.g. talking a lot to maintain control over the conversation).

be distinguished on the basis of the following dimensions ;

1. Socially skilled vs. socially incompetent
2. Low physiological arousal vs. high physiological arousal
3. Rational vs. irrational thinking style
4. Low avoidant vs. strongly avoidant
5. Anxious around famous people vs. anxious around unknown people
6. Fear in groups vs. fear in the company of one person

Patients with social phobia have different strategies to cope with the situations they fear. One of these is drinking alcohol (as self-medication).

Differential diagnostics

• Social anxiety can have several causes other than social phobia;
• Evasive PHS
• Autistic disorder
• Schizoid PHS
• Other phobic disorders (e.g. panic disorder, agoraphobia)
• Body Dysmorphic Disorder

 

Specific phobia

DSM criteria

A specific phobia is characterized by a prominent and persistent fear, provoked by the presence or anticipation of a specific object or situation. When patients are exposed to this stimulus they almost immediately become very anxious (sometimes even have a panic attack). Patients avoid the stimulus, even though they know their fear is unreasonable. The fear hinders them in daily functioning. The diagnosis is only made if the anxiety cannot be better explained by another disorder.
The DSM distinguishes between different types of specific phobias;

1. Animal phobia
2. Natural violence phobia (e.g. height, storm, water, thunder)
3. Blood/injection/injury phobia
4. Situational phobia (e.g. airplane, elevators)
5. Other (e.g. choking, vomiting, contracting illness)

 

Clinical picture

• Although the ‘phobic stimulus’ may differ, the types of phobias are essentially similar, except for blood phobia and swallowing phobia.
• Because the phobic stimulus is often easy to avoid, many people do not seek treatment. Only the patients where anxiety really hinders daily life.
• With an animal phobia, the fear is usually limited to one animal (usually spiders, mice, dogs, cats or horses). The movement of the animal in particular leads to fear.
• Food phobia is more about an aversion to a certain type of food than a fear, which results in disgust/(tendency to) vomit.
• With a swallowing phobia, people do not dare to swallow food because they are afraid of choking. This is dangerous because it can lead to serious weight loss and reluctance to eat in company.
• A blood/injection/injury phobia involves seeing one of these things. This phobia is different from the others because instead of just an increased arousal after seeing the stimulus, a decrease in heart rate and blood pressure occurs after the increased arousal (fainting). In addition, it is less about fear and more about disgust. The fear that exists is a real fear of fainting.

 

Differential diagnostics

As previously mentioned in the DSM criteria, the diagnosis of specific phobia can only be made if there is no other disorder, such as;

• Panic disorder (with/without agoraphobia)
• Compulsive disorder
• Social phobia
• PTSD

 

Obsessive-compulsive disorder/compulsive disorder

DSM criteria

• Obsessive-Compulsive Disorder (OCD), also called compulsive disorder, focuses on obsessions (obsessive thoughts) and/or compulsions (compulsive actions).
• Obsessive thoughts are persistent ideas, thoughts, impulses or images that are experienced, at least initially, as intrusive and pointless. Compulsions are characterized by repetitive, goal-directed and intentional behaviors or mental activities that are performed in response to an obsessive thought or according to certain rules or in a stereotypical manner. This behavior is aimed at neutralizing or preventing discomfort and tension or a feared event or situation and to reduce anxiety. The patient also sees that this is out of proportion.
• The compulsions and/or thoughts must cause significant distress; time-consuming actions, interfering with daily life, etc.

 

Clinical picture

• Eighty percent of people with OCD suffer from obsessions and compulsions. Usually the obsessions precede the compulsions.
• The most common types of obsessive thoughts concern fear of contamination, violence/harming someone and doubt. Common compulsions include counting, cleaning, washing, checking and touching.
• People with OCD try to avoid situations and stimuli that can lead to obsessions and compulsions. They do this passively, by literally avoiding, and actively, by acting (e.g. washing hands).

Types of compulsion that occur in OCD;

• Cleaning compulsion
• Compulsion to control
• Compulsive buying and compulsion to collect (collecting; ‘hoarding’)
• Compulsive counting
• Cleanliness (e.g. placing things symmetrically)
• Neutralizing thoughts (to ‘erase’ the harmful effects of the obsession)

 

Differential diagnostics

OCD can be distinguished from other disorders in a number of ways;

• Agoraphobia
• Psychotic episode
• PTSD
• Hypochondria
• Depression
• Body Dysmorphic Disorder
• Tics

 

Post-Traumatic Stress Disorder (PTSD)

DSM criteria

With PTSD, the person in question has experienced a serious traumatic event in which he or she was intensely anxious or helpless. Three symptom clusters can be distinguished: symptoms related to 1) re-experiencing, 2) avoidance and 3) increased arousal.
The traumatic experience is persistently relived in at least one of the following ways:

• Recurring memories
• Recurring dreams
• A sudden act or feeling as if the event was happening
• An intense psychological suffering when the person is exposed to
• Events that closely resemble or symbolize the traumatic event.
• The person reacts with physical symptoms during events that are very similar to the original traumatic event.

Stimuli that are reminiscent of the event are avoided, or the general responsiveness is numbed (which was not the case before the trauma). This is reflected in at least three of the following aspects:

• Attempts to avoid thoughts and feelings associated with the trauma.
• Attempts to avoid activities, situations, or people that trigger memories of the trauma.
• The inability to remember an important aspect of the trauma.
• A noticeable decrease in interest in other activities.
• A feeling of alienation from others or of not belonging.
• A restriction of affect.
• A feeling of little future prospects.

At least two of the following symptoms of increased arousal must also occur; sleep problems, irritability or outbursts of anger, concentration problems, hypervigilance or exaggerated startle reactions.
PTSD only exists if the symptoms listed above last longer than one month and the disorder leads to clinically significant tension or limits functioning.

Clinical picture

PTSD is the only anxiety disorder whose onset is clearly identifiable. The disorder usually begins a few hours or days after the confrontation with the trauma (but sometimes only years later). PTSD often also occurs with sleep disorders and substance abuse (as self-medication to soothe painful emotions). Depression, suicidal thoughts and actions, phobic fears and aggressive outbursts are also more common.
Characteristics of PTSD;

1. Limited responsiveness (often feeling alienated)
2. Inability to experience emotions (especially love, sexuality)
3. Heavy burden on the environment (often a reason for relationship problems)

A distinction can be made between 2 types of trauma;

1. Type I > one-off, unexpected, short-lived (e.g. natural disaster, rape).
2. Type II> repeated traumatization (e.g. abuse as a child), also called complex PTSD.

 

Differential diagnostics

One must distinguish between PTSD and;

• OCD
• Pathological grief
• Agoraphobia
• People who are deeply impressed by less dramatic events (e.g. death, divorce, etc.)
• Depression
• Specific phobias

 

Generalized Anxiety Disorder (GAD)

DSM criteria

With GAD, the emphasis is on worrying and worrying as a core symptom, along with excessive anxiety. This fear and worry must relate to multiple life circumstances and last for at least six months, with more days when it occurs than when it does not occur. The patient has no control over worrying and worrying.
Complaints associated with worrying and fear are; restlessness, fatigue, concentration problems, irritability, muscle tension complaints and sleeping problems (at least 3 out of 6). This means that someone must be very limited in their daily functioning.

Clinical picture

GAD is sometimes also referred to as diffuse anxiety disorder, as a kind of residual category of anxiety disorders. The focus is therefore on worrying and worrying about things that may happen, together with increased arousal. Patients report tension complaints caused by worrying.
Patients with GAD often experience excessive medication use and frequent alcohol use.

Differential diagnostics

GAS must be distinguished from;

• Panic disorder
• OCD
• Normal concern
• Organic factors
• Depression
• Substance abuse
• Hypochondria

 

Hypochondria

DSM criteria

Hypochondria is defined in the DSM as a preoccupation with the fear or belief of suffering from a serious illness. This preoccupation is based on an interpretation of physical symptoms. Despite adequate medical examination and reassurance, the preoccupation persists. There is a limitation in functioning. The complaints persist for at least six months and cannot be attributed to another disorder. Hypochondria can also be diagnosed with the specification of poor insight. It is often difficult to distinguish this from delusional disorder. Formally, hypochondria is one of the somatoform disorders, but due to the anxiety involved, hypochondria may better be classified as an anxiety disorder.

Clinical picture

In most cases, the preoccupation will relate to diseases such as cancer, serious heart disease, AIDS, cerebral infarction, MS and diseases with a fatal outcome. To reduce anxiety, patients seek reassurance, control their bodies, and avoid anxiety-provoking situations and activities (such as cemeteries, hospitals, etc.).

Differential diagnostics

Hypochondria must be distinguished from;

• Actual illness
• GAS
• Panic disorder
• Somatization disorder
• OCD
• Mood disorder