The symptoms of anxiety can be similar for many people with anxiety disorders – they all involve overactivation of the body’s fight-or-flight system. However, the circumstances and triggers of this overactivation can vary depending on what type of anxiety disorder each person has.
Post-traumatic stress disorder (PTSD)
Living through a traumatic event is a powerful experience, and everyone who does so will be affected in some way. For many people, this might take the form of intrusive memories or nightmares about the trauma, difficulty sleeping, recurring anxiety about things related to the trauma, feelings of numbness or detachment, depression, or distress. These symptoms usually go away in the weeks following the event. If symptoms last more than a month, however, the person might have post-traumatic stress disorder (PTSD). According to the U.S. Department of Veterans Affairs (VA), 78 to 83 percent of people who have acute stress responses to trauma will develop PTSD.
PTSD is nothing to be ashamed of – it’s a common response to surviving a terrible ordeal. The Anxiety and Depression Association of America (ADAA) reports that 7.7 million American adults today have PTSD. They add that women are twice as likely to develop PTSD as men when exposed to trauma. The VA found that as many as 9.7 percent of women and 3.6 percent of men will experience PTSD during their lifetimes.
Symptoms of PTSD take four main categories:
- Re-experiencing symptom
- Avoidance symptoms
- Negative changes in feelings and belief structures
- Fight-or-flight symptoms
- Intrusive memories that make you feel like you are reliving part of the event, called flashbacks
- Sights, sounds, smells, or other things that in some way remind you of the event that can trigger an intrusive memory or panic attack – for example, the sound of a car backfiring reminding you of gunfire
- Nightmares involving themes or images from the event
- Avoiding going places or doing things that remind you of the event or make you nervous, such as driving, crowded areas, or topical movies
- Keeping busy to try to prevent having to think about the event
- Avoiding getting therapy so you don’t have to talk about the event
- Avoiding relationships with others that might lead to emotional vulnerability
- Feeling numb or detached from yourself, your memories, or the world around you
- Shifts in views of the world, such as the belief that the world is inherently dangerous or that no one can be trusted
- Having difficulty feeling positive or loving emotions towards others
- Forgetting or having difficulty recalling details of the traumatic event
- Having difficulty talking about the event
- Hyper-vigilance, such as preferring to sit with your back to the wall in a restaurant, or scanning each person who gets near you for potential concealed weapons
- Panic attacks/anxiety attacks, especially caused by a trigger
- Startling easily in response to surprises or loud noises
- Agitation or irritation with little provocation
- Insomnia or difficulty sleeping
- Difficulty concentrating on tasks
PTSD occurs when the brain’s system for processing and regulating fear goes awry. Normally, after a trauma, the mind reprocesses memories to gradually remove their emotionally laden content, the process by which it “heals” from mental injury. This involves activity in the hippocampus, a region of the brain responsible for forming new memories. A meta-analysis in Progress in Neuro-Psychopharmacology & Biological Psychiatry found that the hippocampus shrinks in response to trauma. Meanwhile, research in Nature Neuroscience also found that smaller hippocampal volume further predicts who will go on to develop PTSD.
The hippocampus isn’t the only brain region involved – a review in the Annals of the New York Academy of Sciences noted that PTSD also features hyperactivity of the amygdala, the region of the brain involved in processing fear, and underactivity of the medial prefrontal cortex (mPFC), a brain region that normally keeps the amygdala in check.
PTSD responds well to cognitive processing/restructuring therapy (CPT/CRT), according to the VA. People may feel “stuck” in the patterns of how they interact with their memories of their trauma, or have a hard time making sense of what has happened to them. This can make it difficult to interact with traumatic memories, presenting a barrier to healing. To solve this, CPT/CRT has four main stages:
- Learn about PTSD symptoms and how therapy will help.
- Become more aware of how trauma has altered your feelings and thoughts, and how these thoughts may be maladaptive.
- Learn skills to challenge erroneous thoughts and manage unwanted feelings, giving you the ability the change how you think and feel about the trauma.
- Understand how treatment has changed your beliefs – what your new beliefs are, and how to go about living your life in the world after recovering from trauma.
Prolonged exposure therapy (PE) can also treat PTSD, reports the VA. In PE, you gradually increase your exposure to the things that scare you in order to retrain your body’s fear responses to learn that they are not, in fact, dangerous. In prolonged exposure therapy, you might:
- Talk through the trauma repeatedly, delving a little deeper into your memories each time.
- Write down an account of your trauma, record yourself reading it, and then listen to the recording over and over to gradually desensitize you to its content.
- Practice exposure in the real world, like going for a short drive out in public (for a veteran who survived a roadside bomb attack) or getting close to another person (for a survivor of a sexual assault).
Another newer treatment for PTSD is eye movement desensitization and reprocessing therapy (EMDR). In EMDR, therapists use a series of tapping motions or short sounds during talk therapy to disrupt the brain patterns that normally trigger the fear response. Using this technique, people are better able to access their traumatic memories and re-encode them in non-traumatic ways. A meta-analysis in PLoS One found that EMDR was useful for reducing PTSD symptoms.
Obsessive-compulsive disorder (OCD)
It’s normal to have a few small rituals you perform to ease anxiety, such as checking for your keys before you leave the house. However, for people with obsessive-compulsive disorder (OCD), these anxieties and the behaviors that are intended to soothe them get out of hand. People with OCD will experience obsessions, or intrusive and unwanted thoughts that they can’t seem to shake, and compulsions, which are behaviors that feel mandatory in order to try to address the obsessions. For example, someone might be obsessed with the thought that every surface around her is covered in germs, and be compelled to wash her hands every time she touches something that might be contaminated.
About 2.2 million American adults have OCD, reports the National Institute of Mental Health (NIMH).
Symptoms of OCD can include:
- Checking and re-checking to make sure things are as they should be
- Overabundance of concern with cleanliness, hygiene, dirt, germs, or contamination
- Worry about accidentally causing harm to others with one’s actions
- Insistence on arranging objects in a certain order or symmetry
- Obsession with making sets complete
- Hoarding unimportant items of little value
- Repeating actions, rituals, or phrases over and over
Symptoms can vary depending on which type of OCD the person has. These include:
- Early-onset OCD, which appears before puberty
- Tic-related OCD, in which the person experiences small involuntary physical or verbal movements
- Scrupulosity OCD, which centers around religious or moral obsessions
- Primary obsessional OCD, which features obsessions but not compulsions (or only mental compulsions)
- “Just right” OCD
- Hoarding OCD
- OCD caused by brain infection, brain injury, or as a side effect of certain medications
OCD is firmly grounded in brain chemistry – the National Alliance on Mental Illness (NAMI) reports that unlike some other mood disorders, OCD does not readily respond to placebo treatment. OCD occurs as a result of imbalances in activity in the basal ganglia, a region of the brain that is responsible for generating movement, and the frontal lobe, which is responsible for regulating such actions. Studies have found that OCD has strong genetic ties as well.
OCD can be treated with medication, therapy, or both. Antidepressant medications can be particularly helpful for OCD – more so than anti-anxiety medications, NIMH says. For many people, the addition of an atypical antipsychotic is also helpful.
As for therapy, OCD responds well to cognitive behavioral therapy (CBT), which can teach new strategies for dealing with anxiety-causing situations without resorting to following compulsions. Another useful therapy is exposure and response prevention (ERP), in which people with OCD practice exposing themselves to things that trigger their compulsions and refraining from engaging in the behaviors, giving them an opportunity to see that their fears do not become reality. Over time, ERP can reduce compulsive behaviors.
Generalized anxiety disorder
We all have our occasional worries, but for people with generalized anxiety disorder (GAD), worries become all-consuming and ever-present. GAD causes people to feel a state of constant or recurring tension and anxiety when there is no apparent cause, or that is out of proportion to any perceived causes. People with GAD often plan for the worst or expect disaster to strike. According to the NIMH, generalized anxiety disorder affects almost 7 million adults, or about 3 percent of the population.
For someone to be diagnosed with GAD, this excessive worry has to last for at least six months. Worries might involve money, work or school, errands or chores, travel, family, or health problems. Symptoms can include:
- Worry, anxiety, and tension
- Agitation or irritability
- Difficulty sleeping or insomnia
- Muscle tension or aches
- Shakiness, dizziness, or weakness
- Difficulty concentrating
- Feeling out of breath
- Trouble swallowing
- Frequently needing to go to the bathroom
GAD occurs in the brain as a result of fear dysregulation, found research from the Archives of General Psychiatry. People with GAD have reduced connectivity between the amygdala, which processes fear, and the prefrontal cortex and anterior cingulate cortex, which regulate the amygdala. This permits the amygdala to activate in an out-of-control manner, causing a general, overactive fear response.
GAD responds well to cognitive behavioral therapy, which can teach new ways of thinking about and reacting to the world that are anxiety-free. In more severe cases, doctors may also prescribe anti-anxiety medications like benzodiazepines, which are useful for treating acute anxiety, or antidepressants like SSRIs, which can be effective at treating both anxiety and depression. People with GAD may also benefit from complementary therapies, like meditation or yoga.
Panic disorder and agraphobiaPeople with panic disorder experience panic attacks, or bouts of intense fear that can last for several minutes. These episodes can include feelings that disaster is imminent or that everything is out of control, even when there is no real danger present. Attacks include a powerful physical response that might feel like a heart attack. Panic attacks can occur without warning, and many people who experience them worry about having another attack.
Symptoms of panic disorder can include:
- Mental symptoms
- Feeling out of control during panic attacks
- Substantial worry about where and when the next attack will happen
- Avoidance of places where panic attacks have previously occurred
- Feelings of guilt or shame about experiencing panic attacks
- Physical symptoms of a panic attack
- Intense feelings of fear
- Pounding or racing heartbeat
- Difficulty breathing
- Dizziness, lightheadedness, or weakness
- Chest pain
- Nausea or stomach pain
- Feeling the need to hide or flee
For some people, avoiding places where they have experienced panic attacks (or are afraid of experiencing an attack) leads them to be reluctant to go out into the world. They may become withdrawn or reclusive, going out as little as possible. This condition is called agoraphobia.
As with general anxiety, panic disorder involves dysregulation of the amygdala, although its exact mechanisms are not yet known. Similarly to general anxiety, panic disorder responds well to CBT and medication. For agoraphobia, exposure therapy may be appropriate to help extinguish the fear response associated with the outside world.
- Mental symptoms
Social phobia or social anxiety disorderIt’s normal to feel embarrassed from time to time, or to be scared of public speaking. However, people with social phobia (or social anxiety disorder) feel intense, debilitating anxiety often days or weeks in advance of social events, and live in fear of embarrassing themselves. About 15 million American adults have social anxiety disorder, reports NIMH.
Symptoms of social anxiety disorder can include:
- Feeling anxious about being around other people
- Having difficulty making and keeping friends
- Avoiding places where there will be crowd or other people
- Worrying about social events far in advance
- Being afraid that other people are judging you
- Being highly self-conscious in front of others
- Having a hard time talking to people, even when you want to be able to
- Blushing, sweating, or trembling around others
- Feeling nauseous or like there are “butterflies” in your stomach around others
Social anxiety involves hyperactivity of the amygdala, like the other anxiety disorders, but also involves hyperactivity of the insula, which is a brain region that processes pain. For people with social anxiety, social experiences can be literally painful, which lends to why they are anxiety-inducing.
According to the ADAA, 36 percent of people with social anxiety disorder will experience symptoms for 10 years or longer before they seek help. Similar to other anxiety disorders, CBT and medication are effective for treating social anxiety disorder. NIMH notes that an older class of antidepressant, monoamine oxidase inhibitors (MAOIs,) is particularly effective for social anxiety, but that they are rarely used as a primary method of treatment because they can interact dangerously with certain foods and other medications.
We all have specific things we dislike or avoid, like touching spiders or flying on airplanes, but people with specific phobias can experience outright terror or panic attacks from encountering certain things or situations. Phobias have two main symptoms: a recurring fear of a specific object or situation that the person recognizes is not actually dangerous, and avoidance of the object or situation to the point where it causes difficulties in life.
Common phobias include fears of:
- Air travel
- Dental procedures
Although the causes of phobias are not fully understood, they have a strong genetic component, and also involve overactivity of the amygdala, NAMI reports.
Phobias respond well to exposure therapy, in which the person gradually increases his exposure to the object of his phobia. For example, someone who is phobic of snakes might start by looking at pictures of snakes, then progress to watching videos of snakes, being in the same room as a snake, and touching a snake to finally holding a snake. By gradually increasing their exposure level and seeing that nothing has gone wrong, people have the chance to slowly extinguish their fear. Medication like benzodiazepines may also be useful to treat acute panic attacks.
Anxiety and drug abuseSince anxiety disorders all involve overactivation of the body’s fight-or-flight system, it makes sense that people with anxiety disorders might try to use substances to treat their symptoms. Depressant drugs, such as alcohol, opiates, or benzodiazepines, are so named because they depress (or lower) this fight-or-flight response. This makes them very alluring to abuse when faced with an anxiety disorder. JAMA Psychiatry found that, in a study of over 43,000 people, those who had anxiety disorders were over twice as likely to abuse alcohol.
People who have anxiety disorders and legitimate prescriptions for benzodiazepines should work closely with their doctor to ensure that their benzodiazepine use stays in line with their prescription and does not become a problem.
At The Recovery Village, we understand how easily anxiety and addiction can spiral into one another, and we want to help. Our expert therapists offer evidence-based treatment to help you or your loved one recover at our comfortable facilities. To learn more, call us today.