Anxiety Disorders Clinical Presentation

  • Author: William R Yates, MD, MS; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Jan 23, 2012
 

History

To rule out anxiety disorders secondary to general medical or substance abuse conditions, a detailed history and review of symptoms is essential. Review use of caffeine-containing beverages (coffee, tea, colas, Mountain Dew), over-the-counter medications (aspirin with caffeine, sympathomimetics), herbal “medications,” or street drugs. Ask the patient’s sleep partner about apneic episodes or myoclonic limb jerks. Concurrent depressive symptoms are common in all of the anxiety disorders. Severe anxiety disorders may produce agitation, suicidal ideation, and increased risk of completed suicide. Always ask about suicidal ideation or suicidal intent. (See Mental Status Examination)

Generalized anxiety disorder

This disorder is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following symptoms:

  • Restlessness or feeling keyed-up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance
  • Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder

Panic disorder

Patients with panic disorder frequently present to the emergency department (ED) with chest pain or dyspnea, fearing that they are dying of myocardial infarction. They typically report a spontaneous sudden onset of fear or discomfort, typically reaching a peak within 10 minutes. Attacks are associated with a constellation of systemic symptoms, including the following (4 or more of these are needed for DSM-IV-TR criteria):

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Shortness of breath or feeling of smothering
  • Choking sensation
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Derealization (ie, feeling of unreality) or depersonalization (ie, being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias (ie, numbness or tingling sensations)
  • Chills or hot flashes

During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation). Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.

Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (eg, avoiding situations or locations) and worry about the implications of the attack or its consequences (eg, losing control, going crazy, dying).

Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn. DSM-IV-TR criteria include 4 or more attacks in a 4-week period or 1 or more attacks followed by at least 1 month of fear of another. Agoraphobia, present in 30% of persons with PD, establishes the diagnosis.

Assess precipitating events, suicidal ideation or plan, phobias, agoraphobia, and obsessive-compulsive behavior. Exclude involvement of alcohol, illicit drugs (eg, cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide [LSD], yohimbine, 3,4-methylenedioxymethamphetamine [MDMA, or ecstasy]), cannabis, and medications (eg, caffeine, theophylline, sympathomimetics, anticholinergics).

Consider symptomatology of other medical disorders, which may manifest with anxiety as a primary symptom.

  • Angina and myocardial infarction (eg, dyspnea, chest pain, palpitations, diaphoresis)
  • Cardiac dysrhythmias (eg, palpitations, dyspnea, syncope)
  • Mitral valve prolapse
  • Pulmonary embolus (eg, dyspnea, hyperpnea, chest pain)
  • Asthma (eg, dyspnea, wheezing)
  • Hyperthyroidism (eg, palpitations, diaphoresis, tachycardia, heat intolerance)
  • Hypoglycemia
  • Pheochromocytoma (eg, headache, diaphoresis, hypertension)
  • Hypoparathyroidism (eg, muscle cramps, paresthesias)
  • Transient ischemic attacks (TIAs)
  • Seizure disorders

Consider other mental illnesses that may result in panic attacks, including schizophrenia, manic disorder, depressive disorder, posttraumatic stress disorder, phobic disorders, and somatization disorder. Assess family history of panic or other psychiatric illness.

Posttraumatic stress disorder

The information elicited from the interview with the patient must satisfy certain diagnostic criteria to make the formal diagnosis. As with many diagnoses, PTSD can be subclinical, in which the criteria are almost but not fully met. Diagnosis is based on criteria from the DSM-IV-TR. The mental status examination should routinely consist of questions about exposure to trauma or abuse.

The first criterion has 2 components: (1) experiencing, witnessing, or being confronted with an event involving serious injury, death, or a threat to a person’s physical integrity and (2) a response involving helplessness, intense fear, or horror (sometimes expressed in children as agitation or disorganized behavior).

The second major criterion involves the persistent reexperiencing of the event in one of several ways. This may involve thoughts or perception, images, dreams, illusions, hallucinations, dissociative flashback episodes, or intense psychological distress or reactivity to cues that symbolize some aspect of the event. However, children reexperience the event through repetitive play, not through perception like adults.

The third diagnostic criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness; this is determined by the presence of 3 or more of the following:

  • Avoidance of thoughts, feelings, or conversations that are associated with the event
  • Avoidance of people, places, or activities that may trigger recollections of the event
  • Inability to recall important aspects of the event
  • Significantly diminished interest or participation in important activities
  • Feeling of detachment from others
  • Narrowed range of affect
  • Sense of having a foreshortened future

The fourth criterion is symptoms of hyperarousal, and 2 or more of the following symptoms are required to fulfill this criterion:

  • Difficulty sleeping or falling asleep
  • Decreased concentration
  • Hypervigilance
  • Outbursts of anger or irritable mood
  • Exaggerated startle response

Fifth, the duration of the relevant criteria symptoms should be more than 1 month, as opposed to acute stress disorder, for which the criterion is a duration of less than 1 month.

Finally, the disturbance is a cause of clinically significant distress or impairment in functioning.

Children may have different reactions to trauma than adults. For children aged 5 years or younger, typical reactions can include a fear of being separated from a parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions, and excessive clinging. Parents may also notice regressive behaviors. Children of this age tend to be strongly affected by their parents’ reactions to the traumatic event.[49]

Children aged 6-11 years may show extreme withdrawal, disruptive behavior, and/or an inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger, and fighting are also common. The child may have somatic complaints with no medical basis. Schoolwork often suffers. Also, depression, anxiety, feelings of guilt, and emotional numbing are often present. Adolescents aged 12-17 years may have responses similar to adults.[49]

Obsessive-compulsive disorder

OCD is diagnosed primarily by presentation and history. Common obsessions include contamination, safety, doubting one’s memory or perception, scrupulosity (need to do the right thing, fear of committing a transgression, often religious), need for order or symmetry, and unwanted and intrusive sexual/aggressive thought. Common compulsions include cleaning/washing, checking (checking locks, stove, iron, safety of children), counting/repeating actions a certain number of times or until it “feels right,” arranging objects, touching/tapping objects, hoarding, confessing/seeking reassurance, and list making.

Once the diagnosis is suspected, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)[50] is an important tool in defining the range and severity of symptoms and monitoring the response to treatment. The Y-BOCS is comprised of 10 items, 5 for obsessions and 5 for compulsions, each scored 0-4 (total score 0-40). For both obsessions and compulsions, these items rate the time spent, interference with functioning, distress, resistance, and control.

The following elements should be covered when obtaining the history; some suggestions for typical interview questions are included.[51]

The first element concerns the nature and severity of obsessive symptoms. The following questions may be asked:

  • Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?
  • When you had these thoughts, did you try to get them out of your head? What would you try to do?
  • Where do you think these thoughts were coming from?

The second element concerns the nature and severity of compulsive symptoms. The following questions may be asked:

  • Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you have done it right?
  • What behavior did you have to do?
  • Why did you have to do the repetitive behavior?
  • How many times would you do it and how long would it take?
  • Do these thoughts or actions take more time than you think makes sense?
  • What effect do they have on your life?

The information appropriate for a full evaluation includes age of onset; a history of tics, either current or past; and a psychiatric review of systems and comorbidities. With regard to the last, OCD is frequently attended by other psychiatric comorbid diagnoses, prominently including major depressive disorder, alcohol and/or substance use disorders, other anxiety disorders, impulse control disorders (eg, trichotillomania, skin-picking), and Tourette and tic disorders (perhaps 40% of individuals with Tourette disorder will have OCD). Therefore, in taking a psychiatric history, the focus should be on identifying such comorbidities, seeking evidence of the following:

  • Mood and anxiety symptoms
  • Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
  • Eating disorders
  • Impulse control disorders, especially kleptomania and trichotillomania
  • ADHD.

The co-occurrence of schizophrenia and OCD is more problematic for a variety of reasons. Not infrequently, individuals with schizophrenia do seem to have significant OC symptoms (sometimes, ironically, caused or exacerbated by the use of the very effective antipsychotic clozapine, whereas adjunctive antipsychotics may lessen treatment-resistant OC symptoms in those who do not have schizophrenia). When OC symptoms are present in someone who has schizophrenia, they may meet criteria for a diagnosis of OCD, but such patients often respond poorly to the usual OCD treatments, and perhaps OCD in schizophrenia has a different pathophysiology.

A family history of OCD, Tourette disorder, tics, ADHD, and other psychiatric diagnoses should be inquired into, as should any current or past substance abuse or dependence. Antecedent infections, especially streptococcal and herpetic infection, should be asked about as well.

Social phobia (social anxiety disorder)

A person with social phobia will typically report a marked and persistent fear of social or performance situations, to the extent that his or her ability to function at work or in school is impaired. Exposure to social or performance situation always produces anxiety, and this fear/anxiety is recognized as excessive. Social or performance situations are avoided or endured with intense anxiety. Avoidance behavior, anticipation, or distress in the feared social or performance setting produces significant impairment in functioning.

Ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is described commonly by people with social phobia.

Agoraphobia

Inquire about any intense anxiety reactions that occur when the patient is exposed to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (eg, being outside the home and alone; in a crowd of unfamiliar people; on a bridge, in a tunnel, in a moving vehicle).

Specific (simple) phobia

If specific phobias are suspected, specific questions need to be asked about irrational and out of proportion fear to specific situations (eg, animals, insects, blood, needles, flying, heights). Phobias can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation, and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.

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Mental Status Examination

A complete mental status examination should be obtained for each patient with anxiety symptoms, assessing appearance, behavior, ability to cooperate with the exam, level of activity, speech, mood and affect, thought processes and content, insight, and judgment. Patients may exhibit physical signs of anxiety such as sweaty palms, restlessness, and distractibility. Patients are generally oriented times 3 and cooperative. Mood may be normal or depressed. Affect is often preserved. Psychotic symptoms are not typical of uncomplicated anxiety disorders. Suicidal ideation should be assessed by asking about passive thoughts of death, desires to be dead, thoughts of harming self, or plans or acts to harm self. Homicidal ideation is uncommon. Cognition is typically intact with no impairment in memory, language, or speech. Insight and judgment are typically intact.

Generalized anxiety disorder

Two main elements of the mental status examination should be assessed in generalized anxiety disorder. The first involves asking about suicidal/homicidal ideation or plan, such as the following:

  • Have you ever wished you were never born, thought you would be better off dead, wish to harm yourself or others, have a plan to harm yourself or others, or ever tried to kill yourself or seriously injure yourself or others?

The second involves formal testing of orientation/recall, such as the following:

  • Does the patient respond when you call them by name (oriented to person)?
  • Is the patient oriented to place and time? When you ask what place, season, day, month, year is it, does the patient respond appropriately?
  • Does the patient have intact short- or long-term recall? Ask the patient to spell the word WORLD forward and backward, count backward from 100 by 7s, recall what he or she did to celebrate his or her birthday last year and the name of his or her first-grade teacher.

Panic disorder

Mental status screening is essential for diagnosis. Standardized examinations include the Primary Care Evaluation of Mental Disorders (PRIME-MD), the Mobility Inventory for Agoraphobia (MIA), the Agoraphobia Cognitions Questionnaire (ACA), and the Body Sensations Questionnaire (BSQ).

No signs on mental status examination are specific for panic disorder. While the patient may or may not appear anxious at the time of interview, their Mini-Mental Status Examination, including cognitive performance, memory, serial-7, and proverb interpretation, should appear intact and consistent with the patient’s educational level and apparent baseline intellectual functioning.

The mental status examination may reveal an anxious-appearing person, although this is not required for diagnosis. Speech may reflect anxiety or urgency, or it may sound normal. Mood may be described as similar to “anxious,” with congruent affect. Incongruent affect should raise consideration for other diagnostic possibilities. Thought processes should be logical, linear, and goal directed. Thought content is particularly important to specifically assess in order to ensure a patient has no suicidal or homicidal thoughts. Acute anxiety, as a form of acute mental anguish, can lead to unsafe or self-injurious behavior. Abnormalities in thought process or thought content (aside from impulsive suicidal thoughts) should prompt reconsideration of other etiologies. Insight and judgment are usually present and intact.

Posttraumatic stress disorder

General appearance may be affected in patients with PTSD. Patients may appear disheveled and have poor personal hygiene. Behavior may be altered. Patients may appear agitated, and their startle reaction may be extreme.

Orientation is sometimes affected. The patient may report episodes of not knowing the current place or time, even though this may not have been evident during the interview. Memory is likely to be affected. Patients may report forgetfulness, especially concerning the specific details of the traumatic event. A pilot study suggests memory abnormalities may not be limited to the traumatic event itself.[52] Concentration is poor, as is impulse control. Speech rate and flow may be altered.

Mood and affect may be changed. Patients may have feelings of depression, anxiety, guilt, and/or fear. Thoughts and perception may be affected. Patients may be more concerned with the content of hallucinations, delusions, suicidal ideation, phobias, and reliving the experience; certain patients may become homicidal. Potential for suicide and homicide must be noted as part of the mental status.

Obsessive-compulsive disorder

A complete mental status examination should be performed. The patient should be evaluated for orientation, memory, disturbances of mood and affect, presence of hallucinations, delusions, suicidal and homicidal risk, and judgment (including whether insight into the irrational nature of their symptoms is still present).

Phobic disorders

In a situation where the patient is acutely confronted with the object of his or her phobia, the patient’s mental status examination is significant for an anxious affect, with a restricted range. Neurovegetative signs (such as tremor or diaphoresis) might be present. The patient also reports feeling anxious (mood) and can clearly identify the reason for his/her anxiety (thought content). The thought content is significant for phobic ideation (unrealistic and out of proportion fears). Insight might be impaired, especially during exposure, but most times the patient has preserved insight and while reporting that they cannot control their feelings, they also acknowledge that the severity of their fears is not justified.

At any other time, a patient with phobic disorder has a mental status within normal limits, with the exception of thought content positive for phobic ideation. Of note, phobic ideas might remain undisclosed unless questions about phobias are specifically asked. Phobias do not present with suicidal or homicidal ideation, but comorbid conditions commonly associated with phobias, including depression and other anxiety disorders, do present with suicidal or homicidal ideation. If comorbid conditions exist, a specific assessment of the suicidal and homicidal risk should also be completed.

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Next

Physical Examination

Because anxiety manifests with a number of physical symptoms, any patient who presents with a de novo complaint of physical symptoms suggesting an anxiety disorder should have a physical examination and basic laboratory workup to rule out medical conditions that might present with anxiety like symptoms (see Differentials).

For a patient who presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be better suited than repeat physical examination and laboratory investigations. (See Mental Status Examination.) While considering anxiety as the primary suspect, the physician should always remember that over time patients with anxiety do develop medical conditions at the same rate as other patients. In other words, a diagnosis of anxiety, while changing the threshold for investigation of physical symptoms, should not deprive the patient of regular follow-up examinations as otherwise indicated.

Generalized anxiety disorder

Common physical signs of generalized anxiety disorder include tremor, tachycardia, tachypnea, sweaty palms, and restlessness.

Typically, children and adults with generalized anxiety disorder also experience uncomfortable physical symptoms including rapid heartbeat, feeling short of breath, increased sweating, stomach cramping, a feeling of a lump in the throat or inability to swallow, frequent need to urinate, dry mouth, nausea, diarrhea, cold and/or clammy hands, headaches, or neck or backaches. A feeling of nervous tension is often accompanied by a feeling of shaking, trembling, twitching, or body aches. Often, children especially are not diagnosed or receive incorrect treatment and they may undergo unnecessary, invasive, or dangerous medical testing and inappropriate medication treatment for supposed presence of physical illnesses and, as a result, experience an increase in the intensity of fear and worry about their health status.[53, 54, 55]

Panic disorder

No signs on physical examination are specific for panic disorder. The diagnosis is made primarily by history.

The patient may have an anxious appearance. A patient presenting in an acute state of panic can physically manifest any anticipated sign of an increased sympathetic state. Tachycardia and tachypnea are common; blood pressure and temperature may be within the reference range, though hypertension may occur as well. Tremors may be noted. Cool clammy skin may be observed. Hyperventilation may be difficult to detect by observing breathing because respiratory rate and tidal volume may appear normal. Patients may have frequent sighs or difficulty with breath holding. Reproduction of symptoms with overbreathing is unreliable. Chvostek sign, Trousseau sign, or overt carpopedal spasm may be present.

The remaining examination findings are typically normal in panic disorder. However, remember that panic disorder is largely a diagnosis of exclusion, and attention should be focused on the exclusion of other disorders.

A panic attack generally lasts 20-30 minutes from onset—rarely more than an hour. Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in the ED.

Posttraumatic stress disorder

Patients may present with physical injuries from the traumatic event (eg, bruises in victims of domestic abuse). Patients with chronic PTSD may present with somatic complaints and, possibly, general medical conditions. Special attention should be paid to the patient’s sleep hygiene. Recent studies suggest that even a single cognitive-behavioral treatment (CBT) for sleep abnormalities can significantly improve daytime PTSD symptoms, as can pharmacological treatments for sleep abnormalities.[56, 57]

Obsessive-compulsive disorder

Evaluate all patients with OCD for the presence of Tourette disorder or other tic disorders, as these comorbid diagnoses may influence treatment strategy. The findings on neurologic and cognitive examination should otherwise be normal. Focal neurologic signs or evidence of cognitive impairment should prompt evaluation for other diagnoses.

Skin findings in OCD may include eczematous eruptions related to excessive washing, hair loss related to trichotillomania or compulsive hair pulling, and excoriations related to neurodermatitis or compulsive skin picking.

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Contributor Information and Disclosures
Author

William R Yates, MD, MS  Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa

William R Yates, MD, MS is a member of the following medical societies: American Academy of Family Physicians and American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Colin Y Daniels, MD  Consulting Staff, Department of Psychiatry, Madigan Army Medical Center

Colin Y Daniels, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Marilyn T Erickson, PhD  Professor Emeritus, Department of Psychology, Virginia Commonwealth University

Disclosure: Nothing to disclose.

Sandra L Friedman, MD, MPH  Assistant Professor of Pediatrics, Harvard University Medical School; Director of Pediatrics, LEND/UCEDD, Department of Medicine, Division of General Pediatrics, Children's Hospital of Boston

Sandra L Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics and American Medical Directors Association

Disclosure: Nothing to disclose.

Angelo P Giardino, MD, PhD, MPH  Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

T Allen Gore, MD, MBA, CMCM, DFAPA  Assistant Professor, Department of Psychiatry, Howard University School of Medicine; Senior Psychiatrist and Director, Medical Education, Comprehensive Psychiatric Emergency Program, District of Columbia Department of Mental Health

T Allen Gore, MD, MBA, CMCM, DFAPA is a member of the following medical societies: American College of Managed Care Medicine, American Psychiatric Association, and National Medical Association

Disclosure: Nothing to disclose.

William M Greenberg, MD  Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Private Practice

William M Greenberg, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Forest Laboratories, Inc. Salary Employment

Robert Harwood, MD, MPH, FACEP, FAAEM  Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chet Johnson  MD, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas; Professor and Chair of Pediatrics, University of Kansas Medical Center

Chet Johnson is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Samuel M Keim, MD  Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joel Z Lucas, MD  Senior Medical Writer, Reckitt Benckiser Pharmaceuticals, Inc

Joel Z Lucas, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and Student National Medical Association

Disclosure: Johnson & Johnson Salary Employment

Kerim M Munir, MD, MPH, DSc  Director of Psychiatry, Division of General Pediatrics, Developmental Medicine Center, Children's Hospital Boston

Kerim M Munir, MD, MPH, DSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Michael C Plewa, MD  Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Mercy Saint Vincent Medical Center

Michael C Plewa, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Adrian Preda, MD  Health Sciences Associate Professor of Psychiatry and Human Behavior, University of California Irvine School of Medicine

Adrian Preda, MD is a member of the following medical societies: International Congress of Schizophrenia Research, Schizophrenia International Research Society, and Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Lemeneh Tefera, MD, FAAEM  Attending Physician, Department of Emergency Medicine, Beth Israel Medical Center

Lemeneh Tefera, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Lauren Claire Tomao, MD, JD  Resident, Department of Emergency Medicine, Albert Einstein College of Medicine, Beth Israel Medical Center

Lauren Claire Tomao, MD, JD is a member of the following medical societies: American Bar Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Bobbi Adams, Sarah C Aronson, MD, Zachary Osborne, MD, Georgianna M Richards-Reid, MD, and Sandra Yerkes, MD, to the development and writing of the source articles.

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Anxiety. Chart showing the female-to-male sex ratio for anxiety disorders. Adapted from Kessler et al, 1994.
Anxiety. Age of onset for anxiety disorders based on specific anxiety disorder type.
Brain structures involved in dealing with fear and stress.
 
 
 
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