50-1 How do generalized anxiety disorder, panic disorder, and phobias differ?

The anxiety disorders are marked by distressing, persistent anxiety or dysfunctional anxiety-reducing behaviors. Let’s take a closer look at three of them:

For the past two years, Tom, a 27-year-old electrician, has been bothered by dizziness, sweating palms, heart palpitations, and ringing in his ears. He feels on edge and sometimes finds himself shaking. With reasonable success, he hides his symptoms from his family and co-workers. But he allows himself few other social contacts, and occasionally he has to leave work. His family doctor and a neurologist can find no physical problem.

Tom’s unfocused, out-of-control, agitated feelings suggest a generalized anxiety disorder, which is marked by excessive and uncontrollable worry. The symptoms of this disorder are commonplace; their persistence, for six months or more, is not. People with this condition worry continually, and they are often jittery, agitated, and sleep-deprived. Concentration is difficult as attention switches from worry to worry. Their tension and apprehension may leak out through furrowed brows, twitching eyelids, trembling, perspiration, or fidgeting from autonomic nervous system arousal.

The person may not be able to identify, and therefore relieve or avoid, the tension’s cause. To use Sigmund Freud’s term, the anxiety is free-floating (not linked to a specific stressor or threat). Generalized anxiety disorder is often accompanied by depressed mood, but even without depression it tends to be disabling (Hunt et al., 2004; Moffitt et al., 2007b). Moreover, it may lead to physical problems, such as high blood pressure.

Women are twice as likely as men to experience generalized anxiety disorder (McLean & Anderson, 2009). This anxiety gender difference was reflected in a Gallup poll taken eight months after 9/11, when more U.S. women (34 percent) than men (19 percent) said they were still less willing than before 9/11 to go into skyscrapers or fly on planes. And in early 2003, more women (57 percent) than men (36 percent) said they were “somewhat worried” about becoming a terrorist victim (Jones, 2003).

Some people with generalized anxiety disorder were maltreated and inhibited as children (Moffitt et al., 2007a). As time passes, however, emotions tend to mellow, and by age 50, generalized anxiety disorder becomes fairly rare (Rubio & López-Ibor, 2007).

For the 1 person in 75 with panic disorder, anxiety suddenly escalates into a terrifying panic attack—a minutes-long episode of intense fear that something horrible is about to happen. Physical symptoms, such as irregular heartbeat, chest pains, shortness of breath, choking, trembling, or dizziness may accompany the panic. One woman recalled suddenly feeling

hot and as though I couldn’t breathe. My heart was racing and I started to sweat and tremble and I was sure I was going to faint. Then my fingers started to feel numb and tingly and things seemed unreal. It was so bad I wondered if I was dying and asked my husband to take me to the emergency room. By the time we got there (about 10 minutes) the worst of the attack was over and I just felt washed out (Greist et al., 1986).

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These anxiety tornados strike suddenly, wreak havoc, and disappear, but they are not forgotten. Ironically, worries about anxiety—perhaps fearing another panic attack, or fearing anxiety-caused sweating in public—can amplify anxiety symptoms (Olatunji & Wolitzky-Taylor, 2009). After several panic attacks, people may avoid situations where the previous panic attacks have struck. If their fear is intense enough, people may develop agoraphobia, fear or avoidance of situations in which escape might be difficult when panic strikes. Given such fear, people may avoid being outside the home, in a crowd, on a bus, or in an elevator.

Charles Darwin began suffering panic disorder at age 28, after spending five years sailing the world. Because of the attacks, he moved to the country, avoided social gatherings, and traveled only in his wife’s company. But the relative seclusion did free him to focus on developing his evolutionary theory. “Even ill health,” he reflected, “has saved me from the distraction of society and its amusements” (quoted in Ma, 1997).

Smokers have at least a doubled risk of panic disorder (Zvolensky & Bernstein, 2005). They also show greater panic symptoms in situations that often produce panic attacks, such as when they hyperventilate (Knuts et al., 2010). Because nicotine is a stimulant, lighting up doesn’t lighten up.

We all live with some fears. But people with phobias are consumed by a persistent, irrational fear and avoidance of some object, activity, or situation. Specific phobias may focus on animals, insects, heights, blood, or close spaces (FIGURE 50.1). Many people avoid the triggers, such as high places, that arouse their fear, and they manage to live with their phobia. Others are incapacitated by their efforts to avoid the feared situation. Marilyn, an otherwise healthy and happy 28-year-old, fears thunderstorms so intensely that she feels anxious as soon as a weather forecaster mentions possible storms later in the week. If her husband is away and a storm is forecast, she may stay with a close relative. During a storm, she hides from windows and buries her head to avoid seeing the lightning.

Not all phobias have specific triggers. Social anxiety disorder (formerly called “social phobia”) is shyness taken to an extreme. People with this disorder have an intense fear of other people’s negative judgments. They may avoid potentially embarrassing social situations—such as speaking up, eating out, or going to parties—or they may sweat or tremble when doing so.

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