In our day-to-day lives, some people are always worried. You will find people referring to them as worrywarts. It impacts so much on their quality of life since they may even not do something because of
the fear. These people may be suffering from generalized anxiety disorder.
Without the presence of panic attacks, most people find it hard to diagnose anxiety disorders. Since generalized anxiety disorder does not have panic attacks it is hard for us to diagnose it. For people with generalized anxiety, disorder worry is a part of their lives. They are excessively worried or tense all day long.
- 1 What is generalized anxiety disorder according to DSM-5 criteria?
- 2 Symptoms of generalized anxiety disorder according to DSM-5
- 3 Prevalence of generalized anxiety disorders
- 4 What is the difference between being worried normally and generalized anxiety disorder?
- 5 Home remedy methods to manage generalized anxiety disorder
- 5.1 Sharing the problem with others
- 5.2 Learning and utilizing the relaxation techniques
- 5.3 Using simple techniques to help in calming down quickly
- 5.4 Exercise
- 5.5 Learning more about anxiety and trying to use the information to help with worry
- 5.6 Diet and limiting the intake of coffee, alcohol, and nicotine
- 5.7 Getting enough sleep
- 6 How can generalized anxiety disorder be treated?
- 7 “The Five Cs” of Generalized Anxiety Disorder
- 8 The final word
- 9 FAQs
What is generalized anxiety disorder according to DSM-5 criteria?
Generalized anxiety disorder is an anxiety disorder defined by excessive and constant fears and worries about general things that affect the capacity to rest and perform routine activities. The fears and worries in most cases are unfounded when compared to the source.
The fear in GAD emanates from several things, situations, or places, unlike specific phobias which present with fear and worry about a specific thing or place, or situation. The main challenge with the fears and worries is that you can’t control them thus they continue repeating themselves in the brain.
GAD, therefore, removes color from your life because of the constant fear, tension, and worry. The feeling is long-lasting and can make life unbearable even though it is less intense as compared to panic attacks.
An example of GAD is when one is worried about how the day will fan out and believes that something will go wrong during the day. This can even make you unable to leave the house because of fear.
One of the GAD patients in our clinic stated, “I am always worried about small things in my life. Worried about what will happen to my son as he goes to school every day, worried about what will happen at work,
worried about my family at home among other worries.
I can’t control the feeling all day long and sometimes for days. For this reason, I am unable to even perform at work and cannot relax at home. Sometimes I cannot even sleep at night”
Symptoms of generalized anxiety disorder according to DSM-5
There are several symptoms associated with GAD. For a person to be diagnosed with GAD according to DSM-5, he or she must have excessive fear, worry, or nervousness for a period of not less than 6 months. The feeling must be present regularly where it should be present in more days within the 6 months than when they are not there.
The feelings must be about several events, situations, or activities. The individual cannot easily control the anxiety/ worry feeling thus meaning they continue repeating themselves in the brain now and then.
The 6 main symptoms of generalized anxiety disorder according
to DSM-5 include:
- Being restless or feeling that you are on the edge
- Experiencing frequent tiredness and also getting easily fatigued
- Having an issue concentrating or feeling as if the mind is blank
- Being easily irritated. Sometimes irritability can be noticed by other people or not.
- Muscle tension. This presents with muscle pains or soreness.
- Having sleep problems where one has trouble getting sleep, staying asleep, being restless as you sleep, or having an unsatisfying sleep.
Out of these 6 main symptoms, you must have at least 3 of them for a period of 6 months to be diagnosed with generalized anxiety disorder. Also, you must have one of the symptoms in more days than when you do not have
it. In children, having 1 of the symptoms for a period of six months is used for diagnosis.
The symptoms of generalized anxiety disorder can be classified into emotional symptoms, behavioral symptoms, and physical symptoms. In addition to the physical symptoms above, most people with GAD also present with nausea, sweating, and diarrhea.
For anxiety diagnosis, it should be noted that the disturbance should not be associated with other medical conditions, use of medications (prescription drugs among other drugs), or abuse of substances like alcohol or recreational drugs. The medical conditions that can cause such a disturbance are for example hyperthyroidism.
Other mental disorders with symptoms similar to generalized anxiety
Also according to DSM-5 criteria for mental disorders, these symptoms must not be from another mental disorder. There are some mental disorders that can present with the same symptoms. Therefore the symptoms must not be better explained by another mental disorder.
Some of the other mental disorders that can present with the same symptoms include:
- Panic disorders where there is a fear or worry about having a panic attack.
- Social anxiety disorder which presents with a negative evaluation of circumstances and people.
- Obsessive-compulsive disorder where one experiences obsessions and compulsions which bring about fear and worry.
- Post-traumatic stress disorder where one experiences negative feelings of fear, worry, and reminders of previous traumatic experiences.
- Separation anxiety disorder which has a marked fear of being separated from familiar places or people in children and adults.
- Illness anxiety disorder where there are strong feelings of anxiety emanating from having a chronic or serious disease.
- Anorexia nervosa where one has strong feelings about gaining weight that is recurrent
- Somatic symptoms disorder where one has several physical complaints which result in fears
- Dysmorphic disorder which presents with feelings of worry about supposed imperfections in personal looks and appearance.
- Schizophrenia or delusional disorder where one has delusional beliefs.
- Depression: Most of the GAD symptoms overlap with those of depression. Therefore it is good to check if the disorder is co-morbid with depression or whether either of the disorder is present.
A person suffering from generalized anxiety disorder may also have another mental disorder co-morbidity. It is therefore hard to diagnose when one has one mental disorder or several. One of the best ways of dealing with this situation is getting transdiagnostic treatment for emotional disorders.
Other disorders where comorbidity with GAD includes bipolar disorder, mood disorders, and psychotic disorders among others.
Prevalence of generalized anxiety disorders
From several surveys/ studies, about 4 to 6 percent of all individuals at one given tie in their lives will suffer from generalized anxiety disorder. This translates to about 15 million to 20 million residents of the United States of America.
Of all the population, women are more susceptible to the disorder than men. The number of cases in women is approximately double the number of cases in men. This is also seen in almost all other anxiety disorders.
Most of the cases of GAD go undiagnosed. This means that they are not treated, where only 40 percent of people suffering from GAD are treated. When generalized anxiety disorder can become chronic. This will mean
the disorder will be present years after the appearance of the first symptoms.
The disorder is more prevalent in persons between 45 and 59 years. For younger and older persons, the cases are less as compared to that age group.
What is the difference between being worried normally and generalized anxiety disorder?
Everyone gets worried at one time in their lives. It is always a worry when we have uncertainty about our finances, relationships, health, exams, and presentations among other reasons. The main issue is severity and duration.
The main differences between a person who is worried normally and one who is suffering from generalized anxiety disorder include:
- GAD interferes with conducting of your daily activities, chores, and responsibilities while normal worry does not interfere with your job, family life, social life, daily chores, and activities.
- People suffering from generalized anxiety disorder find it very hard to control their feelings of fear, worry, and nervousness while in normal worry people can easily control the anxiety.
- The feelings of anxiety in people with GAD are unsettling, stressing, and upsetting whereas in normal people they do not cause significant stress or upsets even though they are distasteful.
- Persons experiencing generalized anxiety disorder tend to worry about several things events or situations expecting the worst while in normal people the worry is about specific real situations.
- The worry, fear, and nervousness experienced in people with generalized anxiety disorder are way above in severity as compared to the causal situation while in normal people the anxiety is comparable.
- The symptoms of anxiety are present almost every day for a period of not less than six months in people with GAD whereas in people experiencing normal worry the anxiety symptoms only last for a short period.
Home remedy methods to manage generalized anxiety disorder
There are several tips that can be used to self-manage anxiety. The methods either help in preventing the occurrence of generalized anxiety disorder symptoms or overcome GAD symptoms when they occur.
Some of the common self-help tips for GAD include:
- Sharing the problem with others
- Learning and utilizing the relaxation techniques
- Using simple techniques to help in calming down quickly
- Learning more about anxiety and trying to use the information to help with worry
- Diet and limiting the intake of coffee, alcohol, and nicotine
- Getting enough sleep
Sharing the problem with others
Sharing worries and fears with others can go a long way in solving the problem. Since human beings are social creatures, it is good to tap into this strength to fight your anxiety. It is therefore important to find someone who is always there to listen to you and try and find solutions together.
This person may be a close family member, a friend, a clergy member, a spouse, or sometimes someone who has experienced GAD before. Some people also find help from a therapist.
This means that as someone who is suffering from GAD, you can find a person or group of persons who can help you to deal with the anxiety. The person must be always available to offer a strong support system in order to cope with anxiety.
It is also important to know the people around you. Some people may even make the anxiety symptoms worse. This person may also be a chronic worrier like you and when you talk to them it drives them and you down the road of more worry. It is therefore good to avoid them when you start worrying.
In addition, GAD may make relationships not work. The worry may affect the way you relate with your spouse, family, friends, colleagues, and other people. Therefore, letting people know the effects of your worry can help them sometimes not to feel offended or hurt when the symptoms appear.
Learning and utilizing the relaxation techniques
There are several relaxation techniques that can be applied to cope with or manage the symptoms of generalized anxiety disorder. Since worry is controlled by body hormones that manage the fight-or-flight actions in the body, learning how to relax can help ease this mechanism.
There are several techniques that can be used to help you relax. They include:
- Deep breathing
- Massage and other muscle relaxation techniques
In deep breathing, a person tries to minimize the effects of hyperventilation that is caused by the fight-or-flight mechanism in the body. This system produces effects that can cause more anxiety or panic.
The fight-or-flight action in the respiratory system that occurs during anxious moments includes faster breathing. In addition, people experience gasping, faintness, lightheadedness, chest pains, and tingly hands and feet.
The deep breaths alternated with counting to 10 can help to calm you down. This breathing can be managed by breathing from the diaphragm thus ensuring the rapid breathing is slowed down.
Mindfulness meditation can help in the regulation of brain chemicals. This helps you to relax when practiced regularly. Mindfulness meditation utilizes breathing techniques, creating a calming mental image, mind
awareness and body awareness to help in body and mind relaxation.
In mindfulness meditation, one tries to keep in touch with the thoughts and body feelings without being judgmental of self. That way your body and brain can focus on the present and prevent anxiety attacks.
Meditation techniques in general help you to relax.
Massage and other muscle relaxation techniques
Massage has been shown to help people to relax and manage anxiety symptoms. There are different massage techniques that can help with anxiety. Massage can be done by a friend, family member, or a qualified massage therapist.
The massage helps in blood circulation and the regulation of body hormones to offer relaxation. Massage also helps the muscles and other body parts to heal thus preventing generalized anxiety from developing.
Progressive muscle relaxation techniques on the other hand make use of alternating and systematic relaxation and tensing of groups of muscles in the body to enable relaxation.
Using simple techniques to help in calming down quickly
Both socializing and using relaxation techniques help to easily calm down. There are several simple techniques that can help to calm you down. These techniques help the brain to get soothed. The technique centers on one or several body senses to relieve anxiety.
These techniques can utilize the following senses:
- Sound: for some people listening to some calming music or even singing can help to calm your nerves. The calming sound can be from a musical instrument, from a favorite song, or from nature sounds (recorded
or live sounds from wind sounds, ocean waves, tree sounds, birds, or insects). As for me, my nerves are calmed by listening to the sounds of birds singing.
- Smell: some aromas and smells can help to calm your body. Some people light the scented candles, spray perfumes, burn incense, or walk in a garden to smell the flowers or natural scents. These smells can
calm your brains.
- Sight: There are things in this life that make us happy when we look at them. These things can look at to give you a sense of calmness. Examples of the things you can look at to ease GAD include a family photo, nature photos, animal pictures, or a calming video.
- Taste: Some things when chewed or tasted can help you to calm down. Some people find chewing gum, eating ice cream, a hot cup of chocolate, or chamomile tea among other treats to be calming.
- Touch: Touch can also be relaxing. Whether it is someone or something touching you or touching something yourself can offer a calming sense for you. You can touch a pet, give yourself a massage, get in the way of a breeze or touch the coarseness of your jeans. These among others distract you from the anxious thoughts helping you to calm down.
- Imagination: Sometimes imagining things that make you happy can offer relief from the anxious thoughts. You can paint a picture of a calming place in your brain where you can always escape to when you
Moving around or exercising can help to get relief from anxiety and also prevent anxiety from happening. Exercise helps the body to reduce tension and regulate the brain chemicals that affect sleep, anxiety, and stress among others.
The exercise can either be intense or light. Both forms of exercise help you to get relief from anxiety. At least 30 minutes of exercises like walking, running, swimming, aerobic activity, or dancing can work for your anxiety.
It is recommended that the exercise can be done while practicing mindfulness to maximize the effects. Mindfulness helps to concentrate on things that bring out positive energy thus combining well with exercises.
Learning more about anxiety and trying to use the information to help with worry
Learning about anxiety can help you to prevent or cope with the anxiety symptoms. Generalized anxiety disorder is an anxiety disorder that is defined by constant worrying or fear about several things that happen in our lives.
Learning about the disorder helps to know what triggers the disorder, how to deal with it, or ways to prevent the disorder. It helps to show you that worrying is counterproductive since the fight-or-flight mechanism has minimal uses in the current world.
When we learn about it we know that we are not protecting ourselves when we get the anxiety symptoms. The materials we read also help to show you that the worry in GAD is more extreme as compared to the causal
trigger or agent.
Sometimes reading also helps us to know that we can always pull through the anxiety. It helps you to understand that anxiety about general things can not harm us. This way we easily stop the recurrence of the anxiety thereafter.
If you are worrying about “what if”, then we are getting worried for nothing. The materials available will help us to learn how to stop worrying, challenging unproductive thoughts, or get through the anxiety with minimal harm to ourselves or our relationships.
There are several materials that we can read or use to learn about anxiety. They include anxiety books, audiobooks, videos, and lectures among others. These materials can be available for free or bought from stores and through the internet.
Diet and limiting the intake of coffee, alcohol, and nicotine
There are changes in our day-to-day meals, drinks, and lifestyle that can help to manage generalized anxiety disorders. They include checking what we eat, drink and smoke.
Anxiety can be controlled by eating a balanced diet and not skipping some meals. This is because a balanced diet is able to give you all the required nutrients to enable your body to function, balance the brain and body chemicals, and repair.
The meal should have lots of fruits and vegetables. These help to regulate the brain chemicals like serotonin and body chemicals like insulin. While reducing the refined sugars and carbohydrates to enable the body to get the right amounts of sugars in the bloodstream.
Skipping meals always leave us hypoglycemic which can trigger anxious thoughts. Therefore wherever you feel that you might not get a meal for some time, kindly carry a snack that can help in energizing the body.
Reduce caffeine intake
There are several effects of caffeine that make generalized anxiety disorder and other disorders worse or trigger them. Caffeine among other stimulants can make you to have a pounding heart, sleeplessness, trembling extremities, restlessness, and irritation.
Some of those effects of stimulants feel like symptoms of generalized anxiety disorder or other disorders and thus can trigger a panic. The effects can also make the GAD symptoms worse.
Avoid alcohol and nicotine
Alcohol makes anxiety symptoms worse especially when it is wearing off from the system. Most people take a few pints of alcohol to mask of the effects of anxiety. You will find someone who has anxiety about being around people taking a few pints to make him sociable. However, when the alcohol is wearing off it can give you a hangover which can trigger anxiety.
Nicotine is also used by several people to try and calm their anxiety. However, nicotine is a stimulant that increases anxiety. Therefore, persons with GAD should not smoke or take alcohol.
Getting enough sleep
It is well known that when we are anxious we find sleep hard to come by. This lack of sleep then makes anxiety worse. It is therefore recommended that we should always strive for enough quality sleep to get relief from anxiety.
The ability to handle stress or think straight when we are sleep-deprived is compromised. This is because of the emotional imbalance that is created by not going through all the sleep stages. Sleep helps to regulate the brain chemicals thus preventing anxiety.
There are several ways to get a good night’s sleep every night. They include:
- Regular exercise
- Minimizing the use of alcohol and stimulants like caffeine and nicotine
- Weight reduction
- Having a regular sleeping pattern and minimizing naps
- Making the bedroom comfortable for sleep
- Not using blue light-emitting devices for some time before sleep
- Working on stress
- Eating meals that will facilitate sleep
How can generalized anxiety disorder be treated?
There are 2 broad ways of treating generalized anxiety disorder and other anxiety disorders. The treatment methods are:
- Use of medications
This is talk therapy whereby by visiting a specialist for anxiety a person suffering from GAD is treated. Cognitive-behavioral therapy (CBT) is one of the most commonly used treatment methods for anxiety. It uses the following components to treat anxiety:
- Physical control strategies
- Cognitive control strategies
- Behavioral strategies.
There are different CBT strategies which are either single diagnostic therapy techniques or transdiagnostic
treatment techniques for emotional disorders. The techniques that work for a single emotional disorder are the single diagnostic therapy techniques while transdiagnostic therapy for emotional disorders works for different emotional disorders. Examples of the transdiagnostic treatment for emotional disorders include the unified protocol, MATCH. CETA, and cognitive therapy among others.
Use of medications for generalized anxiety disorders
There are several medications that can be used for GAD. Some of these medications include:
- Buspirone: It is one of the most effective and safest medications for anxiety. It should be used to manage the symptoms of anxiety but does not eliminate anxiety.
- Benzodiazepines: They are some of the fastest medications for GAD. They however can cause dependence with long-term use. Also, withdrawal from benzodiazepines leads to withdrawal symptoms.
- Antidepressants: There are several antidepressants that are used to treat anxiety. It is good to check the times that it will take to work, the side effects, and the interactions before taking antidepressants. They form the first line of treatment against GAD.
- GABA: It is also used to treat GAD. Since it is a body chemical it is better tolerated than most other medications for anxiety. However, it is good to check on the side effects and effects of GABA.
- Beta-blockers: They are also used for anxiety treatment. Like other medications, it is good to discuss with your doctor before taking the medication for the treatment of generalized anxiety disorder.
“The Five Cs” of Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by excessive and intrusive anxiety and worry about everyday activities and relationships. In other words, people with GAD tend to worry about things that others do not.
Generalized anxiety disorder is one of the most common types of anxiety disorders. It usually begins in early adulthood. It affects between 6.5 and 9.5 percent of Americans at some point in their lives.
If you have generalized anxiety disorder, you may feel anxious about almost everything. You may worry about being able to handle everyday life, be unable to relax, or feel tense and awkward around people.
The five Cs of generalized anxiety disorder offer insights into the causes of the condition, plus strategies you can use to manage your symptoms. These are:
This article describes the five Cs of generalized anxiety disorder and how they play a role in the condition. Each of the five Cs is explained in detail below.
One of the five Cs of generalized anxiety disorder is cognitive, which refers to the thoughts you have. When you have generalized anxiety disorder, your thoughts may be racing and negative, spiraling out of control. You may worry about many different things without being able to stop or think another way.
To help manage these thoughts, you can practice a variety of skills. For example, with mindfulness meditation, you focus on breathing and being aware of your body in the present moment. With cognitive-behavioral therapy (CBT), you learn how to identify and challenge irrational thoughts that are involved in generalized anxiety disorder. Cognitive-behavioral therapy is often used as an effective treatment for generalized anxiety disorder.
The first C is concrete. How do I know if I have GAD?
If you have generalized anxiety disorder, you may feel anxious about almost everything. You may worry about being able to handle everyday life, be unable to relax, or feel tense and awkward around people.
But how do you know for sure? If you are experiencing one or more of the symptoms of GAD on a daily basis, it may be worth seeking professional help. Your doctor can diagnose your condition after an evaluation and rule out other potential health conditions that could be causing your symptoms.
People with generalized anxiety disorder often worry about things that other people do not. This is a common symptom of GAD. It can be difficult to tell the difference between what’s normal and what’s excessive or irrational.
It also can be difficult to see that your worries are unrealistic or exaggerated. In an attempt to ease their anxiety, people with GAD may engage in “catastrophizing,” which involves thinking up the worst possible outcome for a situation. For example, if you were going on a blind date, you might catastrophize by imagining the person being abusive or not liking you at all – even though it is unlikely this would happen.
The Catastrophizing Cycle
Catastrophizing isn’t always helpful because it can lead to panic attacks and make everyday tasks seem impossible. The cycle of catastrophizing usually starts when you think about something that makes you anxious. You worry about the event, then think of all the bad outcomes this might produce; finally, you decide these outcomes will happen for sure and feel overwhelmed by fear. This leaves you feeling helpless and vulnerable as if there is nothing else that can be done to prevent these events from happening.
This cycle will continue until you manage your stress levels and break free from this pattern of thinking .
People with generalized anxiety disorder often use avoidance as a self-protection strategy. They may avoid situations or people they fear will increase their anxiety and prevent them from feeling safe. However, the more you avoid your fears, the more intense they can become.
There are many reasons why people with generalized anxiety disorder may feel compelled to conceal their condition from others. It could be because they worry about how others will react and whether the person will understand what it feels like to have GAD.
It’s important to remember that if you want to successfully manage your condition, you need to tell someone about it sooner rather than later.
CSBT (Cognitive-Behavioral Therapy)
A form of talk therapy that has been shown to be very effective for generalized anxiety disorder is called cognitive-behavioral therapy (CBT). CBT is a type of psychotherapy where you work with a therapist to identify and change the thought and behavioral patterns that maintain your fear. CSBT includes specific techniques that can help you manage your symptoms.
These techniques include:
One technique is called thought stopping. Thought stopping is when you recognize thoughts that are causing you distress and then replace those thoughts with something more positive or less stressful.
The idea behind this technique is to replace negative thoughts with something else so you can take control of them and stop them from taking over. Another CBT technique for managing symptoms is called exposure therapy.
Exposure therapy involves exposing yourself to the situations, objects, or people that make you anxious until your body calms down. For example, if someone with GAD was afraid of speaking in public, his therapist would ask him to speak at an actual event in front of real people before having a panic attack about it in his office.
This would allow him to learn how his body responds in such situations without any consequences so he could gain control over his anxiety around it.
The final word
Generalized anxiety disorder DSM-5 classification criteria is an anxiety disorder that can lower the quality of life. The symptoms of GAD are also found in several other mental disorders or conditions.
A proper diagnosis of generalized anxiety disorder as per the DSM-5 criteria is important in getting an effective treatment or get ways how to prevent or cope with the disorder.
There are treatment methods available to treat GAD. These include several psychotherapy techniques or the use of medications. The two should be explored and the right treatment method used for GAD.
This article discusses generalized anxiety disorder, which is characterized by excessive and intrusive anxiety and worry about everyday activities. The five Cs of GAD are discussed in detail, plus strategies to help manage symptoms. Strategies include cognitive behavioral therapy, meditation, exercise, and more. Generalized anxiety disorder is a common type of anxiety disorder.
It usually begins in early adulthood. It affects approximately 6.5-9.5 percent of Americans at some point in their lives. You may feel anxious about almost everything if you have GAD; you might worry about being able to handle everyday life or being unable to relax or feel tense and awkward around people.
What is the DSM 5 code for generalized anxiety disorder with panic attacks?
The DSM-5, or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most recent edition of this manual. The DSM-5 was published in 2013 and contains a list of diagnostic criteria for generalized anxiety disorder with panic attacks.
The diagnostic criteria for generalized anxiety disorder includes:
• Intense worry, causing significant distress or difficulty carrying out daily functions
• Worry occurring at least three days per week for six months
• Worrying about different things than what would be expected with another anxiety disorder
• The worry is not due to the symptoms of another mental health disorder
• The worry causes significant distress or difficulty carrying out daily functions
What are the five anxiety disorders currently recognized by the DSM-5?
The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. It is used as a tool to diagnose mental health disorders by outlining symptoms, causes, and treatments for them.
As of 2013, there are five anxiety disorders recognized by the DSM-5: Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Post-Traumatic Stress Disorder (PTSD) and Social Phobia.
Can you have generalized anxiety disorder with panic attacks?
It is possible to have both panic disorder and GAD, but most people with GAD do not experience panic attacks. In other words, only about 10% of people with GAD have panic attacks.
If you experience a panic attack, that doesn’t mean you automatically have generalized anxiety disorder. It is possible to have both GAD and panic disorder. Some people may also refer to these as “panic symptoms” or “GAD symptoms.” But it is important to note that these are two separate conditions that can co-occur.
Panic attacks are sudden, intense episodes of fear or discomfort where the person feels like they cannot control their feelings. Panic disorders are diagnosed when a person has at least four panic attacks per month for six months or one attack per month for more than a year without another type of mental health condition. When someone experiences a panic attack, they may feel very afraid, like they can’t breathe, or shake uncontrollably.