Anxiety Disorders: A Comprehensive Overview from a Psychiatric Perspective
Anxiety, when experienced occasionally, is a normal response to stress. However, when it becomes chronic, intense, or disproportionate to the situation, it may signal an anxiety disorder—a group of mental health conditions characterized by excessive fear or worry. From a psychiatric perspective, anxiety disorders are medical conditions rooted in neurobiological, psychological, and environmental factors. They are diagnosable, treatable, and best addressed through a biopsychosocial model of care.
This article outlines common anxiety disorders—generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder—including their symptoms, causes, and evidence-based psychiatric treatments.
Types of Anxiety Disorders (Psychiatric Classification)
Anxiety disorders are classified in the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision). Each has specific diagnostic criteria.
1. Generalized Anxiety Disorder (GAD)
DSM-5-TR Criteria:
- Excessive anxiety and worry, more days than not, for at least six months
- Difficulty controlling the worry
- Associated with at least three of the following:
- Restlessness
- Fatigue
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
Psychiatric Insight:
GAD often presents chronically with fluctuating severity. Psychiatrists rule out conditions like hyperthyroidism. Depression commonly co-occurs.
2. Social Anxiety Disorder (SAD)
DSM-5-TR Criteria:
- Marked fear or anxiety about one or more social situations involving possible scrutiny
- Social situations almost always provoke fear
- Fear is disproportionate and impairs functioning
Psychiatric Insight:
Patients may internalize symptoms, delaying diagnosis. Psychiatrists distinguish between shyness and clinical anxiety. Comorbidities often include avoidant personality disorder or alcohol use.
3. Panic Disorder
DSM-5-TR Criteria:
- Recurrent, unexpected panic attacks
- At least one attack followed by a month of worry about future attacks or consequences
- Symptoms include:
- Palpitations
- Chest pain
- Derealization
- Fear of dying
Psychiatric Insight:
Often confused with cardiac or respiratory issues, panic disorder frequently leads patients to ER visits. Psychiatrists rule out physical causes and start treatment.
Etiology and Neurobiology (Psychiatric Perspective)
1. Neurotransmitter Imbalance
- Involves serotonin (5-HT), norepinephrine (NE), and GABA
- Reduced serotonin and GABA are common in anxiety
2. Brain Structures
- Amygdala: overactive in fear response
- Prefrontal cortex: underactive in emotional regulation
3. Genetics and Environment
- Family and twin studies suggest heritability
- Early trauma, abuse, and chronic stress increase risk
Diagnosis and Psychiatric Evaluation
A complete psychiatric evaluation includes:
- Clinical interview and mental status exam
- Standardized tools (e.g., GAD-7, LSAS)
- Screening for comorbidities (e.g., depression, PTSD)
- Medical and substance use rule-out
- Suicide risk assessment
Treatment Options: A Psychiatric Framework
Treatment is individualized and includes medication, therapy, or both.
1. Pharmacotherapy
First-Line:
- SSRIs (escitalopram, sertraline, paroxetine)
- SNRIs (venlafaxine XR, duloxetine)
Adjunct/Second-Line:
- Buspirone – good for GAD, non-sedating
- Hydroxyzine – antihistamine with calming effect
- Pregabalin – used for GAD/SAD in some countries
Short-Term (Acute Relief):
- Benzodiazepines – effective but risk dependency
- Beta-blockers (propranolol) – for performance anxiety
2. Psychotherapy
Psychiatrists may provide or coordinate with:
- CBT – gold standard
- ERP – for social and panic disorders
- Psychodynamic therapy – for deeper, persistent issues
3. Integrated & Lifestyle Approaches
- Sleep hygiene
- Nutrition and exercise guidance
- Mindfulness-Based Stress Reduction (MBSR)
- Reducing stimulants (e.g., caffeine, nicotine)
When to Refer or Hospitalize
Inpatient care may be needed for:
- Suicidal thoughts/self-harm
- Severe functional impairment
- Co-occurring psychotic or severe mood disorders
Outpatient care is appropriate for most cases.
Prognosis
- Most individuals improve with early and proper treatment
- Maintenance therapy may last 6–12 months or longer
- Untreated anxiety can lead to depression, substance misuse, or disability
Conclusion: The Psychiatrist’s Role in Managing Anxiety
Anxiety disorders are highly treatable. A psychiatrist provides an accurate diagnosis and personalized treatment plan, often combining medication and psychotherapy. Collaborative care with other professionals improves long-term outcomes.
As awareness grows, stigma fades. Early intervention leads to better quality of life.
Dr. Anna Wachtel, MD is a psychiatrist based on Manhattan’s Upper East Side. She provides integrative care for adults experiencing anxiety and related conditions, combining therapy, medication, and lifestyle support. In-person and telepsychiatry sessions are available.