Anxiety and Related Disorders

Photo by: fizkes / Sthutterstock.com

Photo by: fizkes / Sthutterstock.com

Confused about numerous anxiety disorders? This is not surprising because there is a great deal of overlap between them. There is also a lot of misinformation going around about what characterizes each disorder.

Sometimes, it is difficult even for a mental health professional to establish a differential diagnosis. Common diagnostic struggles include questions such as:

-       What is the difference between panic attacks and a panic disorder?

-       Is it a panic disorder or a phobia?

-       Is it illness anxiety or OCD?

-       Is it GAD or OCD?

-       Is it agoraphobia or a simple phobia?

Here is a summary of the most common anxiety disorders and their characteristics*:

Social Anxiety Disorder (Social Phobia)

This is the fear of social situations and, more specifically, of being negatively judged, evaluated, or rejected by others. The sufferers are afraid of being humiliated or embarrassed. The most frequent feared situations are public speaking, talking to unfamiliar people, performing in front of others, eating or drinking in public, or even urinating in a public washroom (a shy bladder syndrome). In more cases than not, social anxiety is generalized across various social situations.

 Socially anxious people are preoccupied with the fear that they will appear weird, stupid, boring, weak, crazy, or unlikable. They may also be worried that others will notice them sweating, blushing, shaking, staring, having an awkward body posture, or speaking too quickly or too slowly.

It is typical for socially anxious people to direct their attention internally during a social interaction. This is called self-focus. Social phobics become acutely aware of their internal sensations and emotions. Often, they also have distorted images of themselves looking and sounding awkward and weird and (mistakenly) perceive these as the evidence of how others see them. These images are based only on their self-perception, but they contribute to even more anxiety.

Another negative consequence of self-focus is that because the person’s attention is directed inwards, many important social cues get missed. This, of course, may objectively interfere with the natural, flexible flow of a social interaction.

Socially anxious people attempt to avoid the discomfort caused by social interactions by staying away from anxiety-provoking situations, and often become isolated.  

Panic Disorder

 Panic disorder is diagnosed when one has recurrent panic attacks and constantly worries about having another attack. The following symptoms frequently occur during the attacks: heart palpitations, sweating, shaking, nausea, feeling of choking, tingling, dizziness, shortness of breath, and fear of dying, losing control, going crazy, or some other imminent catastrophe happening.

The main feature of panic disorder is misinterpreting bodily sensations in a catastrophic way. That is, a person perceives a normal, harmless physical sensation as a sign of impending doom.

The disorder is maintained (and often made worse) by selective attention and monitoring of the physical symptoms, as well as by avoidance and safety behaviours. The purpose of these avoidance and safety behaviours is to try to prevent the feared catastrophe from occurring.

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder is characterized by excessive and seemingly uncontrollable anxiety and worry about a wide range of events or activities, while the person feels restless, fatigued, and irritable. The worry is so omnipresent in the person’s life that it affects daily functioning, as the person has difficulty concentrating, relaxing, and sleeping.

This disorder is characterized by having a “worry chain” – continuously jumping from one “what if?” to another. People with GAD sometimes even worry about not worrying! 

There are several patterns that are typical to people with GAD:

-       They perceive worry as dangerous and are concerned that it may lead to them becoming sick or will make them go crazy. So, not only do they just worry, they also worry about worrying. There is even a name for that – metaworry (a worry about worry).

-       In spite of the above, they also see worry as helpful. That is, they believe worry will help them prepare for the future and make informed decisions.

 -       Somewhat counterintuitively, people with GAD are not as good at vividly imagining the feared catastrophe as non-anxious people. It is theorized that the cognitive process of worry protects them from having disturbing images. That is, constant worrying is still less scary than actually imagining the unimaginable.

-       Another process which usually characterizes all GAD sufferers (and most other people with anxiety, but to a lesser extent) is the inability to tolerate uncertainty [INSERT THE LINK TO THE UNCERTAINTY PART OF ANXIETY BLOG]. As pretty much everything in life is uncertain, this quest for certainty, of course, backfires and the worry continues.

Specific Phobia

This is the fear of a specific object or situation such as animals, heights, thunderstorms, or seeing blood or needles. It is common for a phobic person to have more than one phobia.

People with phobias actively avoid their feared situations or objects. When they can’t avoid, their fear is intensified and may even lead to panic.

Phobias usually develop in childhood. Sometimes there is a traumatic event that precedes the development of a phobia. A person may also learn about the situation or object’s dangers from the media or from another person. In many cases though, there are no identifiable precursors to the development of the fear. 

 Similar to other anxiety disorders, phobias are maintained by selective attention to the environment, catastrophic predictions, and avoidance and safety behaviours.

Phobics tend to overestimate the probability and the extent of harm, while underestimating their ability to cope.

Agoraphobia

This is a fear or anxiety about being in either open or enclosed spaces, using public transportation, being in a crowd, standing in line, or being outside alone. Agoraphobia often accompanies panic disorder.  

Agoraphobia is very similar to a specific phobia. The main difference is that to be diagnosed with agoraphobia, a person must be fearful of at least two agoraphobic situations (say, travelling in a vehicle and being in enclosed spaces). If the fear is limited to only one agoraphobic situation, a diagnosis of specific phobia is made.

Obsessive Compulsive Disorder (OCD)

OCD is characterized by having obsessions and compulsions. Obsessions are recurrent, unwanted, intrusive thoughts, images, or urges that cause anxiety or distress.

Compulsions are behaviours or mental acts aimed at reducing the distress caused by obsessions. Compulsions may be visible or invisible to others (as in “Pure-O” OCD).

What happens with OCD is that a person has a normal, intrusive thought but perceives it as meaningful or dangerous. That is, it’s not the thoughts that drive this disorder; rather, it is giving the thought a lot of attention and trying to get rid of it or neutralize it that turns a thought into an obsession. The more the person engages in overt or mental compulsions, and, thus, the more significance they give to the thought, the “stickier” the thought becomes.

OCD sufferers tend to overestimate the probability of harm, have difficulty handling uncertainty, and often have an overly inflated sense of responsibility.

Some “Pure-O” OCD types, such as an OCD related to constantly questioning whether a person is in the “right” romantic relationship (ROCD), strongly resemble GAD. The constant worrying, engaging with the thoughts, and intolerance of even the slightest uncertainty are common to both disorders.

 The main distinctions are the presence of intrusive thoughts that are often exaggerated and even inappropriate, as well as the presence of rituals in the case of OCD. While the rituals are mental, they are still rituals (such as neutralizing, checking, asking for reassurance, trying to figure things out, etc.). In GAD, however, it is the excessiveness of worry that really characterizes the disorder. In some cases, it may be difficult to distinguish with certainty between the two disorders.

Illness Anxiety

This is the preoccupation with having or getting a serious disorder. It is accompanied by significant anxiety about health and numerous health-related habits such as checking, monitoring, reassurance seeking, or avoiding.

It is common to attend endless medical appointments and repeatedly request unnecessary medical tests. It doesn’t matter if the doctor agrees to the test requisition or not. In either case, it evokes even more anxiety. If the doctor refuses to provide a referral, it is interpreted as the doctor being dismissive and likely to overlook important symptoms. If the doctor succumbs to the pressure and refers, then the patient thinks that something serious must be going on with them for sure; otherwise the doctor wouldn’t have referred them. 

Repeated reassurance seeking usually affects not only the person with illness anxiety and their medical providers, but also their family members.

Spending hours checking the symptoms and Googling medical information interferes with the person’s daily functioning.  

The pattern of this disorder is similar to panic disorder. In both cases, the person catastrophically misinterprets a physical sensation. The main difference is that with a panic disorder the person expects the catastrophe to be imminent, while with illness anxiety the person fears having or acquiring a disease that will cause them suffering or death in the future.

It is also very similar to OCD with intrusive, scary thoughts about getting a disorder resembling the obsessions, and checking, avoidance, reassurance seeking, etc. being the compulsions. People with OCD usually have other obsessions and compulsions, but otherwise, the symptoms (and the treatment) of illness anxiety are pretty much the same as of OCD.

What is Common to all Anxiety Disorders

You may have noticed that many cognitive and behavioural patterns are similar across all the disorders.

In all the disorders described above, there is usually an internal or external trigger that sets off some catastrophic interpretations of it. This evokes anxiety, which, in turn, leads to even more scary thoughts or images. The person then feels very distressed and tries to engage in all kinds of safety behaviours to reduce the distress. They also go to great lengths to avoid the scary trigger the next time. These safety and avoidance behaviours make the trigger and the distress seem even more catastrophic and the cycle continues.  

Treatment of Anxiety Disorders

The treatment of all anxiety disorders involves radically changing the person’s relationship with their anxiety. Instead of building their life around the fruitless struggle to achieve certainty and reducing distress, the person is given tools to unhook from intrusive thoughts and to willingly accept the uncomfortable physical sensations, while making steps toward living a valuable, meaningful life.

The treatment starts with identifying the obstacles that stand in the person’s way of living the life they want (most likely those obstacles would include over-engagement with intrusive thoughts, as well as avoidance and safety behaviours). After that, through a combination of Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Exposure therapy, the therapist helps the person acquire skills to move toward living the life they want to live, instead of being pushed around by their anxiety.


Footnote:

* OCD and illness anxiety are not, strictly speaking, anxiety disorders, but they are very similar to anxiety disorders in their presentation and in the patterns of thinking and behaviour of the individuals who have them. There are also many similarities in the treatment approach for them and for anxiety disorders. They are outlined in separate categories of the DSM-5. 

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

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Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.