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ANXIETY VERSUS ANXIETY DISORDERS
Anxiety is an inevitable part of life in contemporary society. It’s
important to realize that there are many situations that come up in everyday
life in which it is appropriate and reasonable to react with some anxiety,
such as giving a speech, a job interview, or dealing with an angry supervisor
at work. If you didn’t feel any anxiety in response to everyday challenges
involving potential loss or failure, something would be wrong. Normal anxiety
helps you by gearing you up to better cope with a demanding situation.
In contrast to normal anxiety, anxiety disorders disrupt your ability to
cope and deal with daily life. Anxiety disorders are distinguished from
everyday, normal anxiety in that they involve anxiety that 1) is more intense
(for example, panic attacks), 2) lasts longer (anxiety that may persist
for weeks or months instead of going away after a stressful situation has
passed), or 3) leads to phobias that interfere with your life. An anxiety
disorder may lead you to feel anxious most of the time and/or keep you
from engaging in activities or situations you used to handle with ease.
Criteria for diagnosing specific anxiety disorders have been established
by the American Psychiatric Association and are listed in a well-known
diagnostic manual used by mental health professionals. This manual is called
DSM-IV (Diagnostic and Statistical Manual of Mental Disorders—Fourth
Edition), and the following descriptions of various anxiety disorders are
based on it. This site can help you even if your specific anxiety problem
or reaction doesn’t fit any of the DSM-IV’s diagnostic categories.
On the other hand, don’t be unduly concerned if your reaction is
perfectly described by one of the diagnostic categories. Approximately
13 percent of the people in the United States would find themselves in
your company.
Here are the various anxiety disorders defined by DSM-IV:
Panic Disorder
Panic disorder is characterized by sudden episodes of acute apprehension
or intense fear that occur “out of the blue,” without any apparent
cause. Intense panic usually lasts no more than a few minutes, but, in
rare instances, can return in “waves” for a period of up to
two hours. During the panic itself, any of the following symptoms can occur:
 Shortness of breath
or a feeling of being smothered
Heart palpitations—pounding heart
or accelerated heart rate
Dizziness, unsteadiness, or faintness
Trembling or shaking
Feeling of choking
Sweating
Nausea or abdominal distress
Feeling of unreality—as if you’re
“not all there” (depersonalization)
Numbness or tingling in hands and feet
Hot and cold flashes
Chest pain or discomfort
Fears of going crazy or losing control
Fears of dying
At least four of these symptoms are present in a full-blown panic attack,
while having two or three of them is referred to as a limited-symptom attack.
Your symptoms would be diagnosed as panic disorder if you:
1) have had two or more panic attacks and
2) at least one of these attacks has been followed by one month (or more)
of persistent concern about having another panic attack, or worry about
the possible implications of having another panic attack.
It’s important to recognize that panic disorder, by itself, does
not involve any phobias. The panic doesn’t occur because you are
thinking about, approaching, or actually entering a phobic situation. Instead,
it occurs spontaneously and unexpectedly for no apparent reason. Also,
the panic attacks are not due to the physiological effects of a drug (prescription
or recreational) or a medical condition. You
may have two or three panic attacks without ever having another one again
or without having another one for years. Or you may have several panic
attacks followed by a panic-free period, only to have the panic return
a month or two later. Sometimes an initial panic attack may be followed
by recurring attacks three or more times per week unremittingly until you
seek treatment. In all of these cases, there is a tendency to develop anticipatory
anxiety or apprehension between panic attacks focusing on fear of having
another one. This apprehension about having another panic attack is one
of the hallmarks of panic disorder. If
you are suffering from panic disorder, you may be very frightened by your
symptoms and consult with doctors to find a medical cause. Heart palpitations
and an irregular heartbeat may lead to EKG and other cardiac tests, which,
in most cases, turn out normal. (Sometimes mitral valve prolapse, a benign
arrhythmia of the heart, may coexist with panic disorder.) Fortunately,
an increasing number of physicians have some knowledge of panic disorder
and are able to distinguish it from purely physical complaints.
A diagnosis of panic disorder is made only after possible medical causes—including
hypoglycemia, hyperthyroidism, reaction to excess caffeine, or withdrawal
from alcohol, tranquilizers, or sedatives—have been ruled out. The
causes of panic disorder involve a combination of heredity, chemical imbalances
in the brain, and personal stress. Sudden losses or major life changes
may trigger the onset of panic attacks.
People tend to develop panic disorder during late adolescence or their
twenties. In a majority of cases, panic is complicated by the development
of agoraphobia (as described in the following section). Between one and
two percent of the population has “pure” panic disorder, while
about 5 percent, or one in every twenty people, suffer from panic attacks
complicated by agoraphobia.
Current Treatment
All of the following strategies are considered state-of-the-art treatments
for panic disorder. Relaxation
Training
Practicing abdominal breathing and some form of deep muscle relaxation
(such as progressive muscle relaxation) on a daily basis. This helps to
reduce the physical symptoms of panic as well as anticipatory anxiety you
might experience about having a panic attack. A physical exercise program
may also be recommended to reduce anxiety. Panic-Control
Therapy
Identifying and eliminating catastrophic thoughts (such as “I’m
trapped!”, “I’m going to go crazy!”, or “I’m
going to have a heart attack!”) that tend to trigger panic attacks. Interoceptive
Desensitization
Practicing voluntary habituation to the body symptoms of panic, such as
rapid heartbeat, sweaty hands, shortness of breath, or dizziness. Such
symptoms are created deliberately, usually in the therapist’s office.
For example, dizziness might be induced by spinning in a chair or rapid
heartbeat by running up and down stairs. Repeated exposure to unpleasant
body symptoms promotes desensitization, which basically means getting used
to them to the point where they no longer frighten you. Medication
SSRI antidepressant medications such as Paxil, Zoloft, Lexapro, or Celexa—or
benzodiazepine medications such as Xanax, Ativan, or Klonopin—may
be used to reduce severity of panic symptoms. Such medications are best
used in conjunction with the first three strategies above. Lifestyle
& Personality Changes
Some of the lifestyle changes that can reduce your tendency to have panic
attacks include stress management, regular exercise, eliminating stimulants
and sugar from your diet, slowing down and creating “downtime,”
and altering attitudes about perfectionism, the excessive need to please,
and the excessive need to control.
Agoraphobia
The word agoraphobia means fear of open spaces; however, the essence of
agoraphobia is a fear of panic attacks. If you suffer from agoraphobia,
you are afraid of being in situations from which escape might be difficult—or
in which help might be unavailable—if you suddenly had a panic attack.
You may avoid grocery stores or freeways, for example, not so much because
of their inherent characteristics, but because these are situations from
which escape might be difficult or embarrassing in the event of panic.
Fear of embarrassment plays a key role. Most agoraphobics fear not only
having panic attacks but what other people will think should they be seen
having a panic attack.
It is common for the agoraphobic to avoid a variety of situations. Some
of the more common ones include
Crowded public
places such as grocery stores, department stores, restaurants
Enclosed or confined places such as
tunnels, bridges, or the hairdresser’s chair
Public transportation such as trains,
buses, subways, planes
Being at home alone
Perhaps the most common feature of agoraphobia is anxiety about being far
away from home or far from a “safe person” (usually your spouse,
partner, a parent, or anyone to whom you have a primary attachment). You
may completely avoid driving alone or may be afraid of driving alone beyond
a certain short distance from home. In more severe cases, you might be
able to walk alone only a few yards from home or you might be housebound
altogether. I know of one agoraphobic who was unable to leave her bedroom
without being accompanied.
If you have agoraphobia, you are not only phobic about a variety of situations
but tend to be anxious much of the time. This anxiety arises from anticipating
that you might be stuck in a situation in which you would panic. What would
happen, for example, if you were asked to go somewhere you ordinarily avoid
and have to explain your way out of it? Or what would happen if you suddenly
were left alone? Because of the severe restrictions in your activities
and life, you may also be depressed. Depression arises from feeling in
the grip of a condition over which you have no control or that you are
powerless to change.
Agoraphobia, in most cases, appears to be engendered by panic disorder.
At first you simply have panic attacks that occur for no apparent reason
(panic disorder). After a while, though, you become aware that your attacks
occur more frequently in confined situations away from home or when you
are by yourself. You begin to be afraid of these situations. At the point
where you actually start to avoid these situations for fear of panicking,
you’ve started to develop agoraphobia. From that point you might
go on to develop a mild, moderate, or severe problem. In a mild case, you
might feel uncomfortable in confined situations but not actually avoid
them. You continue to work or shop on your own, but do not want to go far
from home otherwise. In a moderate case, you might start to avoid some
situations, such as public transportation, elevators, driving far from
home, or being in restaurants. However, your restriction is only partial,
and there are certain situations away from home or your safe person that
you can handle on your own, even with some discomfort. Severe agoraphobia
is marked by an all-inclusive restriction of activities to the point where
you are unable to leave your house without being accompanied.
Just why some people with panic attacks develop agoraphobia and others
do not is unknown at this time. (There are a few people who develop only
agoraphobia without any panic attacks.) Nor is it understood why some people
develop much more severe cases than others. What is known is that agoraphobia
is caused by a combination of heredity and environment. Agoraphobics may
have a parent, sibling, or other relative who also has the problem. When
one identical twin is agoraphobic, the other has a high likelihood of being
agoraphobic, too. On the environmental side, there are certain types of
childhood circumstances that predispose a child to agoraphobia. These include
growing up with parents who are 1) perfectionist and overcritical, 2) overprotective,
and/or 3) overly anxious to the point of communicating to their child that
the world is a “dangerous place.” The hereditary and environmental
origins of agoraphobia and other anxiety disorders will be explored in
greater depth in the following chapter.
Agoraphobia affects people in all walks of life and at all levels of the
socioeconomic scale. Approximately 80 percent of agoraphobics are women,
although this percentage has been dropping recently. It is possible to
speculate that as women are increasingly expected to hold down full-time
jobs (making a housebound lifestyle less socially acceptable), the percentage
of women and men with agoraphobia may tend to equalize.
Current Treatment
Relaxation Training, Panic Control Therapy, and
Interoceptive Desensitization
Since agoraphobia is usually based on a fear of panic attacks, the same
treatments as were described for panic disorder are utilized. Graded
Exposure
“Exposure” therapy means to face or “expose” yourself
to a feared situation. Situations that you have avoided are gradually confronted
through a process of small incremental steps. Such exposures are conducted
first in imagination and then in real life. For example, if you were fearful
of driving far from home, you would gradually increase the distance you
drive in small increments. A support person might accompany you in the
same car at first, then drive in a second car behind you, and then, finally,
you would practice driving alone. Or, if you were fearful of being home
alone, the person who usually stays with you would leave for only a few
minutes at first and then gradually increase their time away. Over time
you learn to confront and enter into all of the situations you have been
avoiding. Cognitive
Therapy
The aim of cognitive therapy is to help you replace exaggerated, fearful
thinking about panic and phobias with more realistic and supportive mental
habits. You learn to identify, challenge, and replace counterproductive
thoughts with constructive ones. Medication
Current treatment for agoraphobia often utilizes medication. SSRIs such
as Paxil, Zoloft, or Celexa are especially likely to be used for more severe
cases where a person is housebound or highly restricted in what they are
able to do. Low doses of tranquilizers such as Xanax or Klonopin may also
be used to help people negotiate the early stages of exposure. Assertiveness
Training
Since agoraphobics often have difficulty standing up for themselves and
their rights, assertiveness training is frequently part of the treatment. Group
Therapy
Treatment for agoraphobia can be done very effectively in a group setting.
There is much support available in a group, both for realizing that you
are not alone and for completing week-to-week homework assignments.
If you are a therapist interested in leading an agoraphobia treatment group,
you may want to see the article I authored, entitled “The Agoraphobia
Treatment Group,” in the book Focal Group Psychotherapy. Social
Phobia Social phobia is one of the
more common anxiety disorders. It involves fear of embarrassment or humiliation
in situations where you are exposed to the scrutiny of others or must perform.
This fear is much stronger than the normal anxiety most nonphobic people
experience in social or performance situations. Usually it’s so strong
that it causes you to avoid the situation altogether, although some people
with social phobia endure social situations, albeit with considerable anxiety.
Typically, your concern is that you will say or do something that will
cause others to judge you as being anxious, weak, “crazy,”
or stupid. Your concern is generally out of proportion to the situation,
and you recognize that it’s excessive (children with social phobia,
however, do not recognize the excessiveness of their fear).
The most common social phobia is fear of public speaking. In fact, this
is the most common of all phobias and affects performers, speakers, people
whose jobs require them to make presentations, and students who have to
speak before their class. Public speaking phobia affects a large percentage
of the population and is equally prevalent among men and women.
Other common social phobias include
Fear of blushing
in public
Fear of choking on or spilling food
while eating in public
Fear of being watched at work
Fear of using public toilets
Fear of writing or signing documents
in the presence of others
Fear of crowds
Fear of taking examinations
Sometimes social phobia is less specific and involves a generalized fear
of any social or group situation where you feel that you might be watched
or evaluated. When your fear is of a wide range of social situations (for
example, initiating conversations, participating in small groups, speaking
to authority figures, dating, attending parties, and so on), the condition
is referred to as generalized social phobia.
While social anxieties are common, you would be given a formal diagnosis
of social phobia only if your avoidance interferes with work, social activities,
or important relationships, and/or it causes you considerable distress.
As with agoraphobia, panic attacks can accompany social phobia, although
your panic is related more to being embarrassed or humiliated than to being
confined or trapped. Also the panic arises only in connection with a specific
type of social situation.
Social phobias tend to develop earlier than agoraphobia and can begin in
late childhood or adolescence. They often develop in shy children around
the time they are faced with increased peer pressure at school. Typically
these phobias persist (without treatment) through adolescence and young
adulthood, but have a tendency to decrease in severity later in life. Recent
studies suggest that social phobia affects 4 to 5 percent of the U.S. population
and may be more prevalent among men than women. Up to 14 per cent of the
adult population experiences social phobia at some time in their life.
Current Treatment
All of the following interventions are part of the current treatment for
social phobia. Relaxation
Training
Abdominal breathing and deep relaxation techniques are practiced on a regular
basis to assuage physical symptoms of anxiety. Cognitive
Therapy
Fearful thoughts that tend to perpetuate social phobias are identified,
challenged, and replaced with more realistic thoughts. For example, the
thought, “I’ll make a fool of myself if I speak up,”
would be replaced with the idea, “It’s okay if I’m a
bit awkward at first when I speak up—most people won’t be bothered.”
Exposure
Exposure involves gradually and incrementally facing the social situation
or situations you’re phobic about. You might do this first in imagery
and then in real life. For example, if you’re phobic of public speaking,
you might start out giving a one-minute talk to a friend and then gradually
increase, through many steps, both the duration of what you say and the
number of people you speak to. Or, if you have difficulty speaking up in
groups, you’d gradually increase both the length and degree of self-disclosure
of remarks made in a group setting. After each exposure, you’d review
and challenge any unrealistic thinking that caused anxiety.
While the treatment for social phobia can be done on an individual basis,
group therapy is the ideal treatment format. This allows direct exposure
to the situation and stimuli that evoke anxiety in the first place. Staying
on Task
Persons with social phobia tend to focus a lot on how they are doing or
try to gauge other people’s reactions while speaking in a social
situation. Treatment includes training in attention to focus only on the
task at hand, whether conversing with a boss, speaking up in class, or
presenting information to a group. Medication
SSRI medications such as Paxil, Zoloft, Luvox, Lexapro, or low doses of
benzodiazepine tranquilizers such as Xanax or Klonopin may be used as an
adjunct to the cognitive and exposure-based treatments described above.
Sometimes MAO-inhibitor medications such as Nardil or Parnate are used
to treat social phobia with success. Social
Skills Training
In some cases, learning basic social skills such as smiling and making
eye contact, maintaining a conversation, self-disclosure, and active listening
are part of the treatment for social phobia. Assertiveness
Training
Training in assertiveness, the ability to ask directly for what you want
or to say “No” to what you don’t want, is often included
in the treatment.
Specific Phobia
Specific phobia typically involves a strong fear and avoidance of one particular
type of object or situation. There are no spontaneous panic attacks, and
there is no fear of panic attacks, as in agoraphobia. There is also no
fear of humiliation or embarrassment in social situations, as in social
phobia. Direct exposure to the feared object or situation may elicit a
panic reaction, however. The fear and avoidance are strong enough to interfere
with your normal routines, work, or relationships, and to cause you significant
distress. Even though you recognize its irrationalities, a specific phobia
can cause you considerable anxiety.
Among the most common specific phobias are the following: Animal
Phobias.
These can include fear and avoidance of snakes, bats, rats, spiders, bees,
dogs, and other creatures. Often these phobias begin in childhood, where
they are considered as normal fears. Only when they persist into adulthood
and disrupt your life or cause significant distress do they come to be
classified as specific phobias. Acrophobia
(fear of heights).
With acrophobia, you tend to be afraid of high floors of buildings or of
finding yourself atop mountains, hills, or high-level bridges. In such
situations you may experience 1) vertigo (dizziness) or 2) an urge to jump,
usually experienced as some external force drawing you to the edge. Elevator
Phobia.
This phobia may involve a fear that the cables will break and the elevator
will crash, or a fear that the elevator will get stuck and you will be
trapped inside. You may have panic reactions, but you have no history of
panic disorder or agoraphobia. Airplane
Phobia.
This most often involves a fear that the plane will crash. Alternatively,
it can involve a fear that the cabin will depressurize, causing you to
asphyxiate. More recently, phobias about planes being hijacked or bombed
have become common. When flying, you may have a panic attack. Otherwise
you have no history of panic disorder or agoraphobia. Fear of flying is
a very common phobia. Approximately 10 percent of the population will not
fly at all, while an additional 20 percent experience considerable anxiety
while flying. Doctor or Dentist Phobias.
This can begin as a fear of painful procedures (injections, having teeth
filled) conducted in a doctor’s or dentist’s office. Later
it can generalize to anything having to do with doctors or dentists. The
danger is that you may avoid needed medical treatment. Phobias
of Thunder and/or Lightning.
Almost invariably phobias of thunder and lightning begin in childhood.
When they persist beyond adolescence they are classified as specific phobias. Blood-Injury
Phobia.
This is a unique phobia in that you have a tendency to faint (rather than
panic) if exposed to blood or your own pain through injections or inadvertent
injury. People with blood-injury phobia tend to be both physically and
psychologically healthy in other regards.
Illness Phobia.
Usually this phobia involves a fear of contracting and/or ultimately succumbing
to a specific illness, such as a heart attack or cancer. With illness phobias
you tend to seek constant reassurance from doctors and will avoid any situation
that reminds you of the dreaded disease. Illness phobia is different from
hypochondria, where you tend to imagine many different types of disease
rather than focusing on one. Specific
phobias are common and affect approximately 10 percent of the population.
However, since they do not always result in severe impairment, only a minority
of people with specific phobias actually seek treatment. These types of
phobias occur in men and women about equally. Animal phobias tend to be
more common in women, while illness phobias are more common in men.
As previously mentioned, specific phobias are often childhood fears that
were never outgrown. In other instances they may develop after a traumatic
event, such as an accident, natural disaster, illness, or visit to the
dentist—in other words, as a result of conditioning. A final cause
is childhood modeling. Repeated observation of a parent with a specific
phobia can lead a child to develop it as well.
Current Treatment
Since specific phobias generally do not involve spontaneous panic attacks,
some of the treatments for panic such as panic-control therapy, interoceptive
desensitization, and medication are usually not included. Relaxation
Training
Abdominal breathing and deep muscle relaxation are practiced on a regular
basis to reduce symptoms of anxiety that occur both when facing the specific
phobia and when experiencing worry (anticipatory anxiety) about having
to deal with the phobic situation. Cognitive
Therapy
Fearful thoughts that tend to perpetuate the specific phobia are challenged
and replaced. For example, “What if I panic because I feel trapped
aboard an airplane?” would be replaced with more realistic and supportive
thoughts such as: “While I may not be able to leave the airplane
for two hours, I can move around, such as leaving my seat to go to the
bathroom several times if needed. If I start to feel panicky, I have many
strategies for coping that I can use, including abdominal breathing, talking
to my companion, listening to a relaxing tape, or taking medication if
necessary.” Coping statements such as, “I’ve handled
this before and I can handle it again,” or “This is just a
thought; it has no validity,” are also useful. These supportive coping
statements are rehearsed until they are internalized. Incremental
Exposure
This involves gradually facing the phobic situation through a series of
incremental steps. For example, fear of flying would be faced first in
imagination only (imagery desensitization), then by watching planes land
and take off, then boarding a grounded plane, then by taking a short flight,
and, finally, a longer flight. A support person would accompany you first
through all the steps, then you’d try them on your own.
For some phobias, it’s difficult to do real-life exposure. For example,
if you’re afraid of earthquakes, treatment would emphasize cognitive
therapy and then exposure to imagined scenes of earthquakes (or watching
movies about earthquakes).
To sum up, specific phobia is usually a benign disorder, particularly if
it begins as a common childhood fear. Though it may last for years, it
rarely gets worse and often diminishes over time. Typically it is not associated
with other psychiatric disturbances. People with specific phobias are usually
functioning at a high level in all other respects.
Generalized Anxiety Disorder
Generalized anxiety disorder is characterized by chronic anxiety that persists
for at least six months but is unaccompanied by panic attacks, phobias,
or obsessions. You simply experience persistent anxiety and worry without
the complicating features of other anxiety disorders. To be given a diagnosis
of generalized anxiety disorder, your anxiety and worry must focus on two
or more stressful life circumstances (such as finances, relationships,
health, or school performance) a majority of days during a six-month period.
It’s common, if you’re dealing with generalized anxiety disorder,
to have a large number of worries, and to spend a lot of your time worrying.
Yet you find it difficult to exercise much control over your worrying.
Moreover, the intensity and frequency of the worry are always out of proportion
to the actual likelihood of the feared events happening.
In addition to frequent worry, generalized anxiety disorder involves having
at least three of the following six symptoms (with some symptoms present
more days than not over the past six months):
Restlessness—feeling keyed up
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Difficulties with sleep
Finally, you’re likely to receive a diagnosis of generalized anxiety
disorder if your worry and associated symptoms cause you significant distress
and/or interfere with your ability to function occupationally, socially,
or in other important areas.
If a doctor tells you that you suffer from generalized anxiety disorder,
he or she has probably ruled out possible medical causes of chronic anxiety,
such as hyperventilation, thyroid problems, or drug-induced anxiety. Generalized
anxiety disorder often occurs together with depression: a competent therapist
can usually determine which disorder is primary and which is secondary.
In some cases, though, it is difficult to say which came first.
Generalized anxiety disorder can develop at any age. In children and adolescents,
the focus of worry often tends to be on performance in school or sports
events. In adults, the focus can vary. This disorder affects approximately
5 percent of the American population, and may be slightly more common in
females than males (55 to 60 percent of those diagnosed with the disorder
are female).
Although there are no specific phobias associated with generalized anxiety
disorder, one view propounded by Aaron Beck and Gary Emery suggests that
the disorder is sustained by “basic fears” of a broader nature
than specific phobias, such as
Fear of losing control
Fear of not being able to cope
Fear of failure
Fear of rejection or abandonment
Fear of death and disease
Generalized anxiety disorder can be aggravated by any stressful situation
that elicits these fears, such as increased demands for performance, intensified
marital conflict, physical illness, or any situation that heightens your
perception of danger or threat.
The underlying causes of generalized anxiety disorder are unknown. It is
likely to involve a combination of heredity and predisposing childhood
experiences, such as excessive parental expectations or parental abandonment
and rejection. Current Treatment
Relaxation Training
Abdominal breathing and deep relaxation techniques are practiced on a regular
basis to directly reduce anxiety. A physical exercise program may also
be included in the treatment. Cognitive
Therapy
Fearful self-talk underlying specific worry themes is identified, challenged,
and replaced with more realistic thinking. When you worry, you overestimate
the odds of something negative happening and underestimate your ability
to cope if something bad did, in fact, happen. Cognitive therapy aims to
correct both types of distorted thinking. You would also work on changing
negative beliefs or “metabeliefs” about worry itself. These
include both beliefs that worry will help you avoid something negative,
i.e., “If I worry about it, it won’t happen,” as well
fearful beliefs about worry itself such as ”My worries are uncontrollable”
or “I’ll go crazy from worrying.” Realistic self-statements
are consistently practiced and internalized over time. Guided imagery may
also be used to help redirect your mind from preoccupation with worry to
more optimistic themes. Worry
Exposure
In worry exposure, you do repeated and prolonged exposure to fearful images
(your worst case scenarios) of what you’re worried about. In these
images you include strategies you would use to reduce anxiety and cope
with the situation. Reducing
Worry Behaviors
You identify overly cautious “safety behaviors” that tend to
reinforce worrying. For example, if you tend to call your spouse or child
several times a day to check on them, you would reduce the frequency of
this behavior. Problem
Solving
Taking systematic action to solve the problem you’re worried about.
In short, you focus on solutions to the problem that worries you instead
of the worry itself. If there is no practical solution, you work on changing
your attitude toward the situation, i.e., learning to accept what you can’t
change. Distraction
A variety of distraction techniques can be helpful for worries that do
not lend themselves easily to cognitive therapy or problem solving. Common
diversionary activities include talking to a friend, journaling, listening
to music, gardening, exercise, puzzle solving, arts and crafts, cooking,
and the Internet. Medication
For moderate to severe cases of generalized anxiety disorder, SSRI medications
such as Paxil, Zoloft, Luvox, or Celexa may be used. The SNRI medication
Effexor has also been found to be effective in treating generalized anxiety
disorder. Another medication, Buspar, has been used for fifteen years to
treat worry and generalized anxiety. It is no longer considered a first-line
medication, however, as the SSRIs appear to be slightly more effective.
Buspar may sometimes be combined with an SSRI to enhance the SSRI’s
effectiveness. Mindfulness
Practice
Mindfulness is an attitude of simply witnessing the ongoing stream of your
thoughts and feelings in the present moment without judgment. It originated
in Buddhist meditation practice but is now being used as a common treatment
for stress, depression, and generalized anxiety. For further information
about mindfulness practice, see
.
Lifestyle & Personality Changes
Such changes are basically similar to the methods described for panic disorder:
stress management, increased downtime, regular exercise, eliminating stimulants/sweets
from your diet, resolving interpersonal conflicts, and changing attitudes
toward perfectionism, an excessive need to please others, or the excessive
need to control.
Obsessive-Compulsive Disorder
Some people naturally tend to be more neat, tidy, and orderly than others.
These traits can in fact be useful in many situations, both at work and
at home. In obsessive-compulsive disorder, however, they are carried to
an extreme and disruptive degree. Obsessive-compulsive people can spend
many hours cleaning, tidying, checking, or ordering, to the point where
these activities interfere with the rest of the business of their lives.
Obsessions are recurring ideas, thoughts, images, or impulses that seem
senseless but nonetheless continue to intrude into your mind. Examples
include images of violence, thoughts of doing violence to someone else,
or fears of leaving on lights or the stove or leaving your door unlocked.
You recognize that these thoughts or fears are irrational and try to suppress
them, but they continue to intrude into your mind for hours, days, weeks,
or longer. These thoughts or images are not merely excessive worries about
real-life problems and are usually unrelated to a real-life problem.
Compulsions are behaviors or rituals that you perform to dispel the anxiety
brought up by obsessions. For example, you may wash your hands numerous
times to dispel a fear of being contaminated, check the stove again and
again to see if it is turned off, or look continually in your rearview
mirror while driving to assuage anxiety about having hit somebody. You
realize that these rituals are unreasonable. Yet you feel compelled to
perform them to ward off the anxiety associated with your particular obsession.
The conflict between your wish to be free of the compulsive ritual and
the irresistible desire to perform it is a source of anxiety, shame, and
even despair. Eventually you may cease struggling with your compulsions
and give over to them entirely.
Obsessions may occur by themselves, without necessarily being accompanied
by compulsions. In fact, about 20 percent of the people who suffer from
obsessive-compulsive disorder only have obsessions, and these often center
around fears of causing harm to a loved one.
The most common compulsions include washing, checking, and counting. If
you are a washer, you are constantly concerned about avoiding contamination.
You avoid touching doorknobs, shaking hands, or coming into contact with
any object you associate with germs, filth, or a toxic substance. You can
spend literally hours washing hands or showering to reduce anxiety about
being contaminated. Women more often have this compulsion than men. Men
outnumber women as checkers, however. Doors have to be repeatedly checked
to dispel obsessions about being robbed; stoves are repeatedly checked
to dispel obsessions about starting a fire; or roads repeatedly checked
to dispel obsessions about having hit someone. In the counting compulsion,
you must count up to a certain number or repeat a word a certain number
of times to dispel anxiety about harm befalling you or someone else.
Obsessive-compulsive disorder is often accompanied by depression. Preoccupation
with obsessions, in fact, tends to wax and wane with depression. This disorder
is also typically accompanied by phobic avoidance—such as when a
person with an obsession about dirt avoids public restrooms or touching
doorknobs.
It is very important to realize that as bizarre as obsessive-compulsive
behavior may sound, it has nothing to do with “being crazy.”
You always recognize the irrationality and senselessness of your thoughts
and behavior and you are very frustrated (as well as depressed) about your
inability to control them.
Obsessive-compulsive disorder used to be considered a rare behavior disturbance.
However, recent studies have shown that about 2 to 3 percent of the general
population may suffer, to varying degrees, from obsessive-compulsive disorder.
The reason prevalence rates have been underestimated up to now is that
most sufferers have been very reluctant to tell anyone about their problem.
This disorder appears to affect men and women in equal numbers. Although
many cases of obsessive-compulsive disorder begin in adolescence and young
adulthood, about half begin in childhood. The age of onset tends to be
earlier in males than females.
The causes of obsessive-compulsive disorder are unclear. There is some
evidence that a deficiency of a neurotransmitter substance in the brain
known as serotonin, or a disturbance in serotonin metabolism, is associated
with the disorder. This is borne out by the fact that many sufferers improve
when they take medications that increase brain serotonin levels, such as
clomipramine (Anafranil) or specific serotonin-enhancing antidepressants
such as fluoxetine (Prozac), fluvoxamine (Luvox),sertraline (Zoloft), and
paroxetine (Paxil). It also appears that persons with OCD have excessive
activity in certain parts of the brain such as the prefrontal cortex and
the caudate nucleus. Current
Treatment
Relaxation Training
As with all of the anxiety disorders, abdominal breathing and deep relaxation
skills are practiced on a daily basis to help reduce anxiety symptoms. Cognitive
Therapy
Fearful, superstitious, or guilty thoughts associated with obsessions are
identified, challenged, and replaced. For example, the idea, “If
I have a thought of doing harm to my child, I might act on it,” is
replaced with, “The thought of doing harm is just ‘random noise’
caused by the OCD. It has no significance. Just having the thought doesn’t
mean I’ll do it.” Exposure
& Response Prevention (ERP)
This technique consists of exposure to situations that aggravate obsessions,
followed by enforced prevention from performing rituals or compulsions.
For example, if you’ve been washing your hands every time you touch
a doorknob, you’d be instructed to touch doorknobs and either reduce
the number of times you wash your hands or refrain from washing at all.
Similarly, if you check the door five times whenever you leave your house,
you would be required to gradually reduce the number of checks to one.
You and your therapist devise a variety of situations, preferably in your
home setting. Then you continually practice exposing yourself to these
situations and desist from performing the compulsions (response prevention).
Usually your therapist or a support person accompanies you to monitor your
compliance in not performing compulsions.
When your problem involves obsessions only, without compulsions, any neutralizing
thoughts or covert rituals you use to reduce anxiety caused by your obsessions
need to be stopped. You would also work on accepting your obsessions without
trying to make them go away. (For further information on exposure and response
prevention in treating OCD, see the book Stop Obsessing: How to Overcome
Your Obsessions & Compulsions, by Edna Foa and Reid Wilson or The OCD
Workbook, by Bruce Hyman and Cherry Pedrick.) Medication
Medications such as Anafranil and the SSRI medications including Prozac,
Luvox, Paxil, and Zoloft help about 70 percent of persons with OCD. Long-term
use of medication is fairly common with OCD, although in some cases the
cognitive and exposure/response prevention strategies described above may
suffice. Lifestyle & Personality
Changes
Essentially, the same lifestyle and personality changes described for panic
disorder and generalized anxiety disorder apply to OCD.
Post-Traumatic Stress Disorder
The essential feature of post-traumatic stress disorder is the development
of disabling psychological symptoms following a traumatic event. It was
first identified during World War I, when soldiers were observed to suffer
chronic anxiety, nightmares, and flashbacks for weeks, months, or even
years following combat. This condition came to be known as shell shock.
Post-traumatic stress disorder can occur in anyone in the wake of a severe
trauma outside the normal range of human experience. These are traumas
that would produce intense fear, terror, and feelings of helplessness in
anyone and include natural disasters such as earthquakes or tornadoes,
car or plane crashes, rape, assault, or other violent crimes against yourself
or your immediate family. It appears that the symptoms are more intense
and longer lasting when the trauma is personal, as in rape or other violent
crimes.
Among the variety of symptoms that can occur with post-traumatic stress
disorder, the following nine are particularly common:
Repetitive, distressing
thoughts about the event
Nightmares related to the event
Flashbacks so intense that you feel
or act as though the trauma were occurring all over again
An attempt to avoid thoughts or feelings
associated with the trauma
An attempt to avoid activities or external
situations associated with the trauma—such as a phobia about driving
developing after you have been in an auto accident
Emotional numbness—being out of
touch with your feelings
Feelings of detachment or estrangement
from others
Losing interest in activities that used
to give you pleasure
Persistent symptoms of increased anxiety,
such as difficulty falling or staying asleep, difficulty concentrating,
startling easily, or irritability and outbursts of anger
For you to receive a diagnosis of post-traumatic stress disorder, these
symptoms need to have persisted for at least one month (with less than
one month’s duration, the appropriate diagnosis is acute stress disorder—see
below). In addition, the disturbance must be causing you significant distress,
interfering with social, vocational, or other important areas of your life.
If you suffer from post-traumatic stress disorder, you tend to be anxious
and depressed. Sometimes you will find yourself acting impulsively, suddenly
changing residence or going on a trip with hardly any plans. If you have
been through a trauma where others around you died, you may suffer from
guilt about having survived.
Post-traumatic stress disorder can occur at any age and affects 6 to 7
percent of the population. Children with the disorder tend not to relive
the trauma consciously but continually reenact it in their play or in distressing
dreams. Current Treatment
Treatment for post-traumatic stress disorder (PTSD) is complex and multifaceted.
Many of the strategies described above for other anxiety disorders are
helpful, but additional techniques may be used as well. Relaxation
Training
Abdominal breathing and progressive muscle relaxation techniques are practiced
to better control anxiety symptoms. Cognitive
Therapy
Fearful or depressed thinking is identified, challenged, and replaced with
more productive thinking. For example, guilt about having been responsible
for the trauma—or having survived when someone you loved did not—would
be challenged. You would reinforce more supportive, constructive thoughts
such as, “What happened was horrible, and I accept that there is
nothing I could have done to prevent it. I’m learning now that I
can go on.” Exposure
Therapy
A therapist or support person helps you confront fearful situations that
you want to avoid because they trigger strong anxiety. In imaginal exposure,
you would repeatedly go back over fearful memories of events, objects,
and persons associated with the original trauma. In real-life exposure,
you would return to the actual situation where the trauma occurred. For
example, if you were assaulted on an elevator, you would return to the
elevator several times. Repeated exposure helps you to understand that
the fearful situation is no longer dangerous. Medication
SSRI medications such as Paxil, Zoloft, Luvox, Prozac, or Celexa are often
helpful in alleviating PTSD symptoms. Especially when these symptoms are
severe and long-lasting, a course of medication lasting one or two years
might be utilized. Tranquilizers such as Xanax or Klonopin might be used
on a short-term basis.
Support Groups
Support groups are particularly helpful in enabling PTSD victims to realize
that they are not alone. Support groups for rape or crime survivors are
often available in larger metropolitan areas. EMDR
or Hypnotherapy
Eye-movement desensitization and reprocessing (EMDR) or hypnotherapy are
often helpful in enabling PTSD victims to retrieve and work through memories
of the original traumatic incident. These techniques may be used to accelerate
the course of therapy and/or overcome resistance to exposure. It’s
important to add that the treatment for any anxiety disorder may include
marital or family therapy. Interpersonal problems with spouses and/or family
may serve to perpetuate anxiety and undermine the success of treatment
until these issues are addressed. Family therapy is also useful in educating
family members about how to understand, support and, in some cases, set
limits with the family member suffering with the anxiety disorder.
Additional Anxiety Disorders in DSM-IV
The anxiety disorders described above derive from an earlier classification
of anxiety disorders presented in DSM-IIIR (Diagnostic and Statistical
Manual of Mental Disorders—Third Edition, Revised). The newer DSM-IV
classification, which appeared in May 1994, added the following four disorders.
Acute Stress Disorder
Like post-traumatic stress disorder, acute stress disorder involves developing
anxiety and other disabling symptoms after exposure to a traumatic event.
The principal distinction is that the symptoms subside in less than one
month; if the symptoms last beyond one month, the diagnosis is changed
from acute stress disorder to post-traumatic stress disorder. As with post-traumatic
stress disorder, the initial trauma involves exposure to an event that
carries the threat of death or serious injury (for example, military combat,
violent personal assault, sexual assault, natural or manmade disasters,
car accidents, or being diagnosed with a life-threatening illness). Either
during or after the traumatic incident, you have symptoms such as numbness,
detachment, or feelings of unreality or depersonalization. Later you tend
to avoid anything that reminds you of the incident, and have persistent
symptoms of anxiety (difficulty sleeping, irritability, poor concentration,
exaggerated startle response, restlessness). This disturbance typically
interferes with your work and your significant relationships but, as indicated,
lasts no longer than four weeks following the traumatic event.
Agoraphobia Without a History of Panic
Disorder
This particular anxiety disorder
has all of the same features as agoraphobia—such as avoidance of
a variety of situations—but there is no history of having had full-blown
panic attacks. Instead, the focus of your fear is on only one or two symptoms
among all those listed for panic disorder. For example, you might be afraid
only of having heart palpitations if you venture too far from home or go
to a crowded public place. Sometimes the fear is of an incapacitating symptom
not on the list of panic attack symptoms. For example, you might be afraid
to drive long distances and/or to be far from a town because of a fear
of losing bladder control or having a bout of diarrhea.
Only a small percentage of people with agoraphobia do not have a history
of panic disorder (estimates range from 5 to 15 percent). Treatment emphasizes
relaxation, cognitive therapy, and in vivo exposure. Anxiety
Disorder Due to a General Medical Condition
This diagnostic category is reserved for situations in which significant
anxiety (either in the form of panic attacks or generalized anxiety) is
a direct physiological effect of a specific medical condition. Numerous
types of medical conditions can cause anxiety, including endocrine conditions
(hyper- and hypothyroidism, hypoglycemia), cardiovascular conditions (congestive
heart failure, pulmonary embolism), metabolic conditions (vitamin B12 deficiency,
porphyria), and neurological conditions (vestibular problems, encephalitis). Substance-Induced
Anxiety Disorder This category is used
when panic attacks or generalized anxiety is determined to be the direct
physiological effect of a substance, whether a drug of abuse, a medication,
or toxin exposure. The anxiety may be a result either of exposure to the
substance or withdrawal from it. For example, if you had no previous history
of an anxiety disorder, then suddenly developed panic attacks as a result
of withdrawing too quickly from a medication, you would receive this diagnosis.
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