When a normal alarm will not stand down

Anxiety is described as a normal emotional response when a threat or danger is sensed. It becomes a serious psychological problem when it is too strong, or when it gets in the way of daily life. In the 2018 third edition of Modern Abnormal Psychology, chapter 4, Kwon Seok-man follows how that turn happens, and sets the types against the seven subtypes laid out in DSM-5-TR. The chapter is fullest on generalized anxiety, the phobias, social anxiety, and panic. Separation anxiety, and play as a way for a child to show fear, appear more briefly.

Generalized anxiety is chronic anxiety and excessive worry in many situations, also called generalized anxiety disorder. People who have it fuss over almost everything, stay uneasy, startle at small things, and live on edge. The anxiety moves from theme to theme across the whole of life, and is therefore also called free-floating anxiety. They are irritable, snap easily, and tire quickly. Lasting tension often brings muscle pain, chronic fatigue, headache, trouble sleeping, indigestion, and irritable bowel symptoms. Under DSM-5-TR, all six diagnostic items, A through F, have to be met.

It is slightly more common in women — about 60 percent of cases — and tends to begin in the mid-teens to early twenties. It often worsens in stressful stretches, and the symptoms can last a lifetime. The core symptom is excessive worry. The main themes, in work cited from Sanderson and Barlow in 1990 and from Tallis and others in 1992, are family, incompetence at work or at school, money, uncertainty about the future, relationships, and physical illness. Yu Seong-jin, in 2000, ties a habit of worry to a critical turn of mind, perfectionism, a low tolerance for uncertainty, and low confidence in solving problems.

Treatment is described as less well developed than for other disorders, even though the problem is very common; more methods have been offered lately. The drugs most often prescribed are the benzodiazepines. They lower hypersensitivity to stimulation and have a sedating effect that quiets thought and action, but in some people the sedation does not appear. Taken in large amounts they can impair thinking and behaviour, and make work, study, or driving hard. Taken for a long time they bring tolerance, and stopping them brings withdrawal. Cognitive behavioural work, developed more recently for this disorder, first helps a person understand the thoughts that feed the worry, then asks them to notice that inner process, and, in the session, to bring up the usual worries and test whether they are realistic and useful.

Phobias: a specific object, an open square, a watching room

A phobia is intense fear of an object or a situation, together with a wish to avoid it. It is divided by what is feared: specific phobia, agoraphobia, and social phobia, also called social anxiety disorder. Specific phobia is a common problem. Lifetime prevalence in the general population is given as 10 to 11.3 percent, and a one-year rate as 9 percent; those figures are left with the reports as given. Under DSM-5-TR, the fear is of a particular object or situation — flying, heights, animals, an injection, the sight of blood — and exposure almost always brings an immediate fear. People try to avoid what they fear, though some endure it in distress. The fear has to be excessive given the real risk and the cultural setting, and the fear and avoidance have to last six months or more and cause marked distress or a clear interference with social or working life. DSM-5-TR divides specific phobia into four subtypes by the kind of object. Among adults who come to clinic, the situational type is the most common, then the natural-environment type, the blood-injection-injury type, and the animal type.

Agoraphobia is fear of particular places or situations. Under DSM-5-TR, the person has marked fear or anxiety in at least two of five: using public transport, being in an open space such as a car park, a market, or a bridge, being in an enclosed space such as a shopping mall or a theatre, standing in a line or in a crowd, and being outside the house alone. The reason for the fear or the avoidance has to be a thought that panic-like, helpless, or embarrassing symptoms would arrive — in an older person, a fear of falling, or of losing control of the bladder — and that escape would be hard or help would not be there. With a companion, the situation can often be endured, still with anxiety. The situational type of specific phobia can look similar, and can even involve the same places; the distinction is that agoraphobia needs two or more of the five situations, while fear limited to one may be diagnosed as a situational specific phobia. Agoraphobia often arrives together with a panic attack. Lifetime prevalence is given as 0.6 to 6 percent, depending on the instrument, and a one-year rate among Americans as about 1.7 percent. It can appear in childhood, but onset is higher in late adolescence or early adulthood, and it is two to four times more common in women.

Social anxiety is a marked fear of one or more social situations in which a person may be watched and judged, and a fear of behaving in a way, or of showing anxiety, that would draw a negative judgement. Exposure almost always brings severe anxiety, and the person tries to avoid the situation. The anxiety and the avoidance have to be excessive given the real risk and the cultural setting, last six months or more, and cause marked distress or a clear interference with social or working life. Lifetime prevalence is given as 3 to 13 percent, higher than for other anxiety disorders. It often appears with other anxiety disorders, and some people never come for treatment, living instead by avoiding social ties. In general-population studies women are more often named; in clinical samples men are as many, or more. It often begins in the mid-teens, in a young person who was shy and inward as a child, and tends to run a chronic course and to grow heavier with time.

A psychoanalytic view reads unconscious conflict as projected onto social situations. Object-relations theory, from the same broad tradition, holds that the early relationship with the mother who raised the child has a bearing on social anxiety. Common cognitive traits are named: a deep belief that one is not a person others would like, a strong drive to leave a good impression, and a habit of judging one’s own behaviour in social situations harshly. Other people’s judgements matter a great deal; the person tries to appear perfect in order to be liked, and treats a negative judgement as a disaster. After repeated anxiety and frustration, avoidance can come to seem the best way through. Cognitive behavioural treatment is described as cognitive restructuring of those negative thoughts and beliefs, repeated exposure such as speaking in front of a group, role play in which speaker and audience trade places, and relaxation training. More recently, mindfulness- and acceptance-based treatment, MABT, has been reported as effective, with a similar effect to cognitive behavioural work in several studies. Medicine is also used, but the trouble tends to return when it is stopped.

Panic, and a child’s fear of being left

Panic disorder is the repeated experience of a sudden, intense wave of anxiety — a panic attack. The attack is an unexpected surge of extreme fear, a sharp sense that one might die. Under DSM-5-TR, the diagnosis of an attack needs that sudden intense fear together with four or more of thirteen listed sensations: a racing or pounding heart, sweating, trembling, shortness of breath or a feeling of being smothered, a feeling of choking, pain or tightness in the chest, nausea or abdominal pain, dizziness or a feeling of faintness, chills or heat, numbness or tingling, a sense that things are unreal or that one is detached from oneself, a fear of losing control or of going mad, and a fear of dying. The sensations rise suddenly and reach a peak within ten minutes. For panic disorder, after such an attack, at least one of two further features is needed: ongoing worry about another attack or about its aftermath — loss of control, a heart attack, a break with reality — or a clear, unhelpful change in behaviour, such as giving up exercise or avoiding unfamiliar situations in order not to bring an attack on. Anticipatory anxiety, even in a quiet stretch, is a central feature: a continuing worry that it will happen again, and a worry about what would follow.

It can appear at any age, but mainly in youth, from late adolescence to the mid-thirties; the mean age of onset is given as 25. The illness tends to become chronic. About 50 percent of patients live with mild symptoms, and 10 to 20 percent live with considerable symptoms and real suffering. Of those whose illness has become chronic, 40 to 80 percent experience depression, and the possibility of suicide is described as high. Some also misuse alcohol or other drugs, and some show obsessive symptoms or hypochondria together with the panic. These figures are left with the reports as given.

Separation anxiety is described, more briefly, as an emotional disorder in which a person shows severe anxiety about being apart from an attachment figure. Inappropriate parenting is named as an important factor in bringing it on. Play therapy is described as a useful treatment for children whose words are not yet ready: through play they can show the anxiety and work on the problem. The same Korean report, at fuller length, is on CampusDown.

Sources

1. Kwon Seok-man, Modern Abnormal Psychology, 3rd ed., Hakjisa, 2018, chapter 4, with diagnoses set against DSM-5-TR.
2. Sanderson and Barlow, 1990; Tallis and others, 1992, on the themes of worry in generalized anxiety; Yu Seong-jin, 2000, on personality traits tied to a habit of worry.

Last updated: 14 November 2026