ANXIETY
June 1, 2000

Anxiety Disorders

Kathryn J. Zerbe, M.D.
Psychodynamic therapy works best with those who are curious to learn more about themselves and their inner thoughts.
Kathryn J. Zerbe, M.D., is Jack Aron Professor in Psychiatric Education and Women's Mental Health, The Menninger Clinic, Topeka, Kansas.


Anxiety disorders are the most prevalent of the psychiatric disorders. They are two to three times more frequent in women than in men, negatively influence the quality of a person's life, lead to costly medical workups and cause general deterioration in overall health and well-being. The impact of these disorders is enormous. The economic cost, for example, of anxiety disorders has been estimated at $47 billion dollars. Fortunately, anxiety disorders are highly treatable conditions for the majority of sufferers.

Anxiety is the unpleasant emotional affect, usually accompanied by physiological sensation, that is characterized by worry, doubt and painful awareness that one is powerless to control situations. In contrast to fear, anxiety is irrational. The anxious person is hypervigilant, tense and insecure in most situations. Their heightened negative state leads to some of the bodily complaints that can be particularly prominent. These include excess sweating, trembling, dizziness, heart palpitations, shortness of breath, gastrointestinal upset, hot flashes, dry mouth, increased urination, fatigue and restlessness. The anxiety episodes can become so intense that individuals believe they are actually "going crazy" or will die.

There are a number of different anxiety disorders, the common types of which are listed below in Table 1.

Table 1.
Common Anxiety Disorders
Based on the American Psychiatric Association Diagnostic and Statistical Manual, DSMIV, 1994, Washington, DC, American Psychiatric Press.

Generalized anxiety disorder (GAD)

As its name implies, this anxiety disorder is characterized by a general sense of excessive worry and tension. It often begins in childhood or early adulthood. It is chronic, or ongoing, and highly treatable.

Panic disorder

Key symptom is a paroxysm of sudden fear together with physiological symptoms that may seem to resemble a heart attack (palpitations, chest pain, choking, vertigo, trembling, shaking); distorted perceptions in light/sound intensity are also common. Panic attacks, as they are called, usually last only a few seconds or a few minutes. They may lead to agoraphobia (see below).

Posttraumatic stress disorder (PTSD)

Anxiety that results from severe stress. It is characterized by unwanted and recurring flashbacks to the traumatic event. Battlefield experiences, rape and childhood sexual abuse are often implicated.

Phobia

Distinguished by a person's avoidance of specific objects or places (such as avoiding snakes or bridges) because they arouse intense fear or panic; common phobias are fear of animals and heights.

Social phobia

Profound shyness, including a fear of humiliation or embarrassment producing avoidance of social situations.

Agoraphobia

Fear associated with being away from a safe person or safe place, such as home. It is frequently seen in those with panic disorder as they seek to avoid having a panic attack in public. It often occurs in people who experience panic attacks because they come to fear leaving the house lest they have a panic attack and embarrass themselves.

Obsessive-compulsive disorder (OCD)

Characterized by repetitive intrusive, unwanted and disturbing thoughts (obsessions), such as thinking one's hands are dirty or that one's home will catch on fire, combined with rituals and behaviors such as compulsively needing to return home to check the stove or washing one's hands hundreds of times a day to reduce the anxiety provoked by the obsessions. There are many variations, including eating disorders and compulsive shopping.


What Causes Anxiety?
The precise cause of anxiety is not known for sure and is most often today viewed as the result of a mix of influences - situational, biological and psychological - that varies from person to person. Anxiety disorder frequently occurs after a major life event (such as the loss of a spouse or parent or physiological stress resulting from physical illness) but a third of individuals with diagnosed panic disorder, for example, will have some recurrent panic attacks in their sleep, and about 4% will have more attacks while they are sleeping than when awake. In fact, some people first experience the illness with a panic attack that interrupts their sleep, sometimes resulting in extensive cardiovascular testing because the individual awakens believing he or she is having a heart attack. All of this suggests that there is some underlying physical basis to at least certain anxiety disorders.
Why Don't People Seek Help?

True to the saying, "The only thing you have to fear is fear itself," the person experiencing an anxiety disorder may spend quite a bit of energy avoiding his or her fear and may or may not be aware that he or she could do something about it - beyond the avoidance tactics (staying at home, avoiding places with elevators, washing hands) that characterize the disorders themselves, that is. What are some of the reasons for this avoidance? Some people find it painful to seek help for their anxiety because they feel it is their personal defect, rather than the fairly common, and often biochemically-based, symptom that it is. They may also lack the knowledge necessary to ease their concerns about what they may believe is the stigma associated with having an emotional problem, or they may believe the problem is a purely physical one.

Take, for example, one person, call him Mr. A:

One day Mrs. A., wife of Mr. A. for 30 years, calls their family doctor because she is noticing "something seems different" about her husband. She describes him as "cranky" and always complaining about "feeling sick." He has refused to come in for his annual physical because he is terrified that the doctor will not find anything new. Although he still goes to work and is productive, Mrs. A. tells the doctor she almost has to push him to go out of the house. While at home, he "fiddles and has the jitters" and recently confided to their son and daughter-in-law that he thinks, "I might drop over dead one of these days from a heart attack. Every now and again I feel like my heart is just going to burst through my chest. I almost pass out. I breathe so fast, get sick to my stomach, and my legs start to give way."

Because some people feel greater anguish at a psychiatric rather than a medical diagnosis, they will sometimes become angry or haughty if friends, family or their primary physician suggest that they may have an emotional condition.

Hopefully, this article and a discussion with your family physician will be the start of a process of education about anxiety disorders and their treatment. This is the quickest way to reduce any misguided shame a person might feel. Often, just talking with a doctor or counselor about the symptoms one is experiencing and learning more about the nature of anxiety can demystify it to some degree. Anxiety is a straightforward and very treatable condition. In many cases treatment results in the person's feeling as though they are living for the first time.

Drugs and Medical Conditions Contributing to Inaccurate Evaluation
Though people experiencing anxiety sometimes prefer to attribute their symptoms to physical conditions, there are real medical conditions that may cause what looks like anxiety. These must always be ruled out. Drugs like amphetamines and cocaine, caffeine and alcohol may all precipitate anxiety attacks. Numerous medical conditions mimic many of the symptoms of anxiety, and some disorders in particular must be ruled out: coronary conditions6 are frequently accompanied by dread and apprehension; hyperthyroidism, systemic lupus erythematosus, anemia, as well as respiratory conditions, such as asthma, chronic obstructive pulmonary disease and pneumonia can all result in symptoms that can be confused with anxiety.

There are also many medications, both prescription and over-the counter, that can precipitate anxiety. Your nutrition should also be considered. Look carefully at the amount of caffeine in coffee, soda, diet soda, chocolate and some aspirin preparations (e.g., Excedrin®) likely to be circulating in your system. precipitate or exaggerate anxiety. Even small amounts of caffeine in some at-risk individuals can precipitate or exaggerate anxiety.
Are There Any Other Risk Factors?
Although it can be helpful to determine one's particular anxiety disorder, in reality, most people having an anxiety disorder have another comorbid (that is, co-occuring and often related) psychiatric condition such as depression, alcoholism or more than one anxiety disorder. We are humans, not textbook cases; rarely, does a person present with a pure anxiety disorder.

Depression
When anxiety and depression occur together, greater functional impairment results. Proper treatment needs to take into account both conditions, and a person's willingness to follow through with treatment is very important. Close family members of the person can be helpful, as they are often the first to notice a change of mood or function.

Alcohol and Substance Abuse
About 15% of individuals with an anxiety disorder also suffer from a substance abuse disorder. They may drink or take prescription or non-prescription drugs to medicate their anxiety. More common is the substance-abusing person who also has an anxiety disorder. This person's attitude toward medication is such that he or she wants higher doses of prescribed medication ("It's not relaxing me enough, Doc"). If the person suffers from anxiety and substance abuse disorder, they may need to be referred to appropriate mental health professionals and community resources (e.g., Alcoholics Anonymous, Narcotics Anonymous). Serious addiction needs to be treated first, before anxiety, because it is progressive and potentially fatal.

Life Events and Trauma
As mentioned earlier, anxiety can be a person's way of reacting to significant loss or trauma in their lives. It is, after all, a sense that something terrible is likely to happen. One research group found that 48.5% of women with an anxiety disorder in their sample had a history of childhood sexual abuse. Although sexual abuse has most frequently been linked with posttraumatic stress disorder, these investigators were surprised to find high rates of panic disorder, obsessive-compulsive disorder and depression in the people they studied. Moreover, samples of battered women, Vietnam War veterans and victims of political persecution also had an increased incidence of anxiety.

A Lack of Close Personal Relationships
People who live alone or have few social interactions and even fewer close ties (and have few social contacts) are more likely to experience anxiety than those with a good social support system. It is sometimes the case that the anxiety itself has hampered a person's life so much that he or she is isolated; but it is also true that loneliness and not having anyone to talk to about concerns can result in fears mushrooming. For example, an elderly person who believes that important items are suddenly missing may become fearful that he or she is the victim of theft and become anxious and suspicious. Having someone else to test this idea out on and, perhaps, getting some help in finding the misplaced items or discovering that forgetfulness is the source of the problem can prevent such fears from taking hold.

Available Treatments
At present, there are three highly effective and specific types of treatment for anxiety disorders:
  1. medication
  2. cognitive-behavioral therapy
  3. psychodynamic treatment.
Since patients and anxiety disorders respond to different treatments differently, it is impossible to know, which interventions will most benefit a specific person. For example, in some people, selective serotonin reuptake inhibitors or SSRIs (which include antidepressants such as Zoloft® or Prozac®) will work very well, while, for others, they may actually make the anxiety worse. Similarly, some people respond best to psychodynamic psychotherapies geared toward providing insight into childhood experiences and conflicts which may be behind the anxiety, while others prefer a more here-and-now approach, such as that offered by the cognitive-behavioral therapy which is geared toward uncovering the habitual thought patterns that contribute to anxiety. Often, a combination of drugs and psychotherapy provide the most lasting treatment.

For background information on psychodynamic and cognitive behavioral therapy, and an introduction to the medicines available for the treatment of anxiety, click here. You should discuss the specifics of drug therapies for anxiety and depression with your doctor.

With the treatments available today, anxiety really should not be dominating your life. If you feel that fear has too prominent a place in your day-to-day choices and behavior, talk to your doctor or a mental health professional. Fear is not the only thing you have to fear - more worrisome is not taking action on your own behalf. Many people who could be helped with this condition are not because they feel ashamed. Resources at your local bookstore or a support group might be good places to start if you having trouble finding the courage to seek help. By reading about or talking with others who have a similar condition, you'll "bootleg" some of the courage you may need to get help with anxiety. Remember, anxiety in the 21st Century is a very treatable illness. If left untreated, it affects the entire family and is so costly to your sense of self worth, productivity and enjoyment of life.

For more information on anxiety disorders, as well as other psychiatric disorders, Dr. Zerbe has written Women's Mental Health in Primary Care, which is available at bookstores and on the Web. The book contains guidelines to help you overcome anxiety and depression and refers you to other sources of information that can help.
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