Mental Abberation: Anxiety

Anxiety

Exact Definition: Heightened fear or tension that causes psychological and physical distress; the American Psychiatric Association recognizes six types of anxiety disorders, which can be treated with medications or through counseling.
Key Terms & Definitions

anxiety: abnormal fear or tension, which may occur without any obvious trigger

brain imaging: any of several techniques used to visualize anatomic regions of the brain, including X rays, magnetic resonance imaging, and positron emission tomography

compulsion: a repetitive, stereotyped behavior performed to ward off anxious feelings

GABA/benzodiazepine receptor: an area on a nerve cell to which gamma aminobutyric acid (GABA) attaches and that causes inhibition (quieting) of the nerve; benzodiazepine drugs enhance the attachment of GABA to the receptor

obsession: a recurrent, unwelcome, and intrusive thought

panic: a sudden episode of intense fearfulness

Information on Anxiety

Causes: Abnormality in common neurotransmitter receptor complex, genetics, emotional or psychological events;

Symptoms: Motor tension (muscle tension, trembling, fatigue) and autonomic hyperactivity (shortness of breath, palpitations, cold hands, dizziness, gastrointestinal upset, chills, frequent urination);

Duration: Often chronic, with discrete episodes lasting five to forty minutes;

Treatments: Sedatives, psychotherapy

Causes and Symptoms

Anxiety is a subjective state of fear, apprehension, or tension. In the face of a naturally fearful situation, anxiety is a normal and understandable condition. When anxiety occurs without obvious provocation or is excessive, however, anxiety may be said to be abnormal or pathological (existing in a disease state). 

Normal anxiety is useful because it provides an alerting signal and improves physical and mental performance. Excessive anxiety results in a deterioration in performance and in emotional and physical discomfort.

There are several forms of pathological anxiety, known collectively as the anxiety disorders. As a group, they constitute the fifth most common medical or psychiatric disorder. In the United States, 14.6 percent of the population will experience anxiety at some point in their lives. More women suffer from anxiety disorders than do men, by a 2:1 ratio.

The anxiety disorders are distinguished from one another by characteristic clusters of symptoms. These disorders include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, phobias, adjustment disorder with anxious mood, and post-traumatic stress disorder. The first three disorders are characterized by anxious feelings that may occur without any obvious precipitant, while the latter three are closely associated with anxiety-producing events in a person’s life.

Generalized anxiety disorder is thought to be a biological form of anxiety disorder in which the individual inherits a habitually high level of tension or anxiety that may occur even when no threatening circumstances are present. Generally, these periods of anxiety occur in cycles which may last weeks to years. The prevalence is unknown, but this disorder is not uncommon. The male-to-female ratio is nearly equal.

Evidence suggests that generalized anxiety disorder is related to an abnormality in a common neurotransmitter receptor complex found in many brain neurons. These complexes, the GABA/benzodiazepine receptors, decrease the likelihood that a neuron will transmit an electrochemical signal, resulting in a calming effect on the portion of the brain in which they are found. These receptors exist in large numbers in the cerebral cortex (the outer layer of the brain), the hippocampus (a structure inside the temporal lobe shaped like a sea horse), and the amygdala (the almond-shaped gray matter inside the temporal lobe). The hippocampus and amygdala are important parts of the limbic system, which is significantly involved in emotions. Benzodiazepine drugs enhance the efficiency of these receptors and have a calming effect. In contrast, if these receptors are inhibited, feelings of impending doom result.

Panic disorder is found in 1.5 percent of the United States population, and the female-to-male ratio is 2:1. This disorder usually begins during the young adult years. Panic disorder is characterized by recurrent and unexpected attacks of intense fear or panic. Each discrete episode lasts about five to twenty minutes. These episodes are intensely frightening to the individual, who is usually convinced he or she is dying. Because people who suffer from panic attacks are often anxious about having another one (so-called secondary anxiety), they may avoid situations in which they fear an attack may occur, in which help would be unavailable, or in which they would be embarrassed if an attack occurred. This avoidance behavior may cause restricted activity and can lead to agoraphobia, the fear of leaving a safe zone in or around the home. Thus, agoraphobia (literally, “fear of the marketplace”) is often secondary to panic disorder.

Panic disorder appears to have a biological basis. In those people with panic disorder, panic attacks can often be induced by sodium lactate infusions, hyperventilation, exercise, or hypocalcemia (low blood calcium). Highly sophisticated scans show abnormal metabolic activity in the right parahippocampal region of the brain of individuals with panic disorder. The parahippocampal region, the area surrounding the hippocampus, is involved in emotions and is connected by fiber tracts to the locus ceruleus, a blue spot in the pons portion of the brain stem that is involved in arousal.

In addition to known biological triggers for panic attacks, emotional or psychological events may also cause an attack. To be diagnosed as having panic disorder, however, a person must experience attacks that arise without any apparent cause. The secondary anxiety and avoidance behavior often seen in these individuals result in difficulties in normal functioning. There is an increased incidence of suicide attempts in people with panic disorder; up to one in five have reported a suicide attempt at some time. The childhoods of people with panic disorder are characterized by an increased incidence of pathological separation anxiety and/or school phobia.

Obsessive-compulsive disorder (OCD) is an uncommon anxiety disorder with an equal male-to-female ratio. It is characterized by obsessions (intrusive, unwelcome thoughts) and compulsions (repetitive, often stereotyped behaviors that are performed to ward off anxiety). The obsessions in OCD are often horrifying to the afflicted person. Common themes concern sex, food, aggression, suicide, bathroom functions, and religion. Compulsive behavior may include checking (such as repeatedly checking to see if the stove is off or the door is locked), cleaning (such as repetitive hand-washing or the wearing of gloves to turn a doorknob), or stereotyped behavior (such as dressing by using an exact series of steps that cannot be altered). 

Frequently, the compulsive behaviors must be repeated many times. Sometimes, there is an exact, almost magical number of times the behavior must be done in order to ward off anxiety. Although people with OCD have some conscious control over their compulsions, they are driven to perform them because intense anxiety results if they fail to do so.

The most common psychological theory for OCD was proposed by Sigmund Freud, who believed that OCD symptoms were a defense against unacceptable unconscious wishes. Genetic and brain imaging studies, however, suggest a biological basis for this disorder. Special brain scans have shown increased metabolism in the front portion of the brain in these patients, and it has been theorized that OCD results from an abnormality in a circuit within the brain (the cortical-striatal-thalamic-cortical circuit). Moreover, OCD is associated with a variety of known neurological diseases, including epilepsy, brain trauma, and certain movement disorders.

Phobias are the most common anxiety disorders. A phobia is an abnormal fear of a particular object or situation. Simple phobias are fears of specific, identifiable triggers such as heights, snakes, flying in an airplane, elevators, or the number thirteen. Social phobia is an exaggerated fear of being in social settings where the phobic person fears he or she will be open to scrutiny by others. This fear may result in phobic avoidance of eating in public, attending church, joining a social club, or participating in other social events. Phobias are more common in men than in women, and they often begin in late childhood or early adolescence.

In classic psychoanalytic theory, phobias were thought to be fears displaced from one object or situation to another. For example, fear of snakes may be a displaced fear of sex because the snake is a phallic symbol. It was thought that this process of displacement took place unconsciously. Many psychologists now believe that phobias are either exaggerations of normal fears or that they develop accidentally, without any symbolic meaning. For example, fear of elephants may arise if a young boy at a zoo is accidentally separated from his parents. At the same time that he realizes he is alone, he notices the elephants. He may then associate elephants with separation from his parents and fear elephants thereafter.

Adjustment disorder with anxious mood is an excessive or maladaptive response to a life event in which the individual experiences anxiety. For example, an individual may become so anxious after losing a job that he or she is unable to eat, sleep, or function and begins to entertain the prospect of suicide. While anxiety is to be expected, this person has excessive anxiety (the inability to eat, sleep, or function) and a maladaptive response (the thought of suicide). The exaggerated response may be attributable to the personality traits of the individual. In this example, a dependent person will be more likely to experience an adjustment disorder than a less dependent person.

Adjustment disorders are very common. In addition to adjustment disorders with anxious mood, people may experience adjustment disorders with depressed mood, mixed emotional features, disturbance of conduct, physical complaints, withdrawal, or inhibition in school or at work. These disorders are considered to be primarily psychological.

Post-traumatic stress disorder (PTSD) is similar to adjustment disorder because it represents a psychological reaction to a significant life event. PTSD only occurs, however, when the precipitating event would be seriously emotionally traumatic to a normal person, such as war, rape, natural disasters such as major earthquakes, or airplane crashes. In PTSD, the individual suffers from flashbacks to the precipitating event and “relives” the experience. These episodes are not simply vivid remembrances of what happened but a transient sensation of actually being in that circumstance. For example, a Vietnam War veteran may literally jump behind bushes when a car backfires.

People who suffer from PTSD usually are anxious and startle easily. They may be depressed and have disturbed sleeping and eating patterns. They often lose normal interest in sex, and nightmares are common. These individuals usually try to avoid situations that remind them of their trauma. Relationships with others are often strained, and the patient is generally pessimistic about the future.

In addition to the anxiety disorders described, abnormal anxiety may be caused by a variety of drugs and medical illnesses. Common drug offenders include caffeine, alcohol, stimulants in cold preparations, nicotine, and many illicit drugs, including cocaine and amphetamines. Medical illnesses that may cause anxiety include thyroid disease, heart failure, cardiac arrhythmias, and schizophrenia.

Treatment and Therapy

When an individual has difficulty with anxiety and seeks professional help, the cause of the anxiety must be determined. Before the etiology can be determined, however, the professional must first realize that the patient has an anxiety disorder. People with anxiety disorders often complain primarily of physical symptoms that result from the anxiety. These symptoms may include motor tension (muscle tension, trembling, and fatigue) and autonomic hyperactivity (shortness of breath, palpitations, cold hands, dizziness, gastrointestinal upset, chills, and frequent urination).

When an anxiety disorder is suspected, effective treatment often depends on an accurate diagnosis of the type of anxiety disorder present. A variety of medications can be prescribed for the anxiety disorder. In addition, several types of psychotherapy can be used. For example, patients with panic disorder can be educated about the nature of their illness, reassured that they will not die from it, and taught to ride out a panic attack. This process avoids the development of secondary anxiety, which complicates the panic attack. Phobic patients can be treated with systematic desensitization, in which they are taught relaxation techniques and are given graded exposure to the feared situation so that their fear lessens or disappears.

The origin, diagnosis, and treatment of anxiety disorders can best be portrayed through case examples. Three fictional cases are described below to illustrate typical anxiety disorder patients.

Ms. Smith is a twenty-four-year-old married mother of two young children. She works part-time as a bookkeeper for a construction company. Her health had been good until a month ago, when she began to experience spells of intense fearfulness, a racing heart, tremors of her hands, a dry mouth, and dizziness. The spells would come on suddenly and would last between ten and fifteen minutes. She was convinced that heart disease was causing these episodes and was worried about having a heart attack. As a result, she consulted her family physician.

Physical examination, electrocardiogram, and laboratory studies were all normal. Her physician had initially considered cardiac arrhythmia (abnormal rhythm of the heartbeat) as a cause but diagnosed panic disorder on the basis of Ms. Smith’s history and the outcome of the tests. Treatment consisted of medication and comforting explanations of the nonfatal nature of the disorder. Within three weeks, the panic attacks stopped altogether.

This case illustrates many common features of panic disorder. The patient is a young adult female with classic panic attacks striking “out of the blue.” Most patients fear that they are having a heart attack or a stroke or that they are going insane. Typically, they present their symptoms to general medical physicians rather than to psychiatrists. Treatment with medication and simple counseling techniques is usually successful.

Mr. Jones is a thirty-five-year-old single man who works as an accountant. He has always been shy and has adopted leisure activities that he can do alone, such as reading, gardening, and coin collecting. As a child, he was bright but withdrawn. His mother described him as “high-strung,” “a worrier,” and “easily moved to tears.” Recently, he has been bothered by muscle achiness, frequent urination, and diarrhea alternating with constipation. He thinks constantly about his health and worries that he has cancer.

Mr. Jones makes frequent visits to his doctor, but no illness is found. His doctor tells him that he worries too much. The patient admits to himself that he is a worrier and has been his whole life. He ruminates about the details of his job, his health, his lack of friends, the state of the economy, and a host of other concerns. His worries make it hard for him to fall asleep at night. Once asleep, however, he sleeps soundly. Finally, Mr. Jones is given a tranquilizer by his physician. He finds that he feels calm, no longer broods over everything, falls asleep easily, and has relief from his physical symptoms. To improve his social functioning, he sees a psychiatrist, who diagnoses a generalized anxiety disorder and an avoidant (shy) personality disorder.

This case illustrates many features of patients with generalized anxiety disorder. These individuals have near-continuous anxiety for weeks or months that is not clearly related to a single life event. In this case, some of the physical manifestations of anxiety are prominent (muscle tension, frequent urination, and diarrhea). Difficulty falling asleep is also common with anxiety. In contrast, patients who are depressed will often have early morning wakening. In this case example, the patient also has a concomitant shy personality that aggravates his condition. Such a patient usually benefits from treatment. Medication may be required for many years, although it may be needed only during active cycles of anxiety. Because some patients attempt to medicate themselves with alcohol, secondary alcoholism is a potential complication.

Ms. Johnson is a forty-two-year-old married homemaker and mother of four children. She works part-time in a fabric store as a salesclerk. She is friendly and outgoing. She has also been very close with her family, especially her mother. Ms. Johnson comes to her family physician because her mother has just had a stroke. Because her mother lives on the other side of the country, Ms. Johnson needs to take an airplane if she is to get to her mother’s bedside quickly. 

Unfortunately, Ms. Johnson has a long-standing fear of flying; even the thought of getting into an airplane terrifies her. She has not personally had a bad experience with flying but remembers reading about a plane crash when she was a teenager. She denies any other unusual fears and otherwise functions well.

Her family physician refers her to a psychologist for systematic desensitization to relieve her phobia for future situations. As a stopgap measure for the present, however, she is taught a deep-muscle relaxation technique, is shown videotapes designed to reduce fear of flying, and is prescribed a tranquilizer and another drug to reduce the physical manifestations of anxiety (a beta-blocker). This combination of treatments allows her to visit her mother immediately and, eventually, to be able to fly without needing medication.

This case illustrates a typical patient with an isolated phobia. Phobias are probably the most common anxiety disorders. Treatments such as those described above are usually quite helpful.

Perspective and Prospects

Anxiety has been recognized since antiquity and was often attributed to magical or spiritual causes, such as demoniac possession. Ancient myths provided explanations for fearful events in people’s lives. Pan, a mythological god of mischief, was thought to cause frightening noises in forests, especially at night; the term “panic” is derived from his name. An understanding of the causes of panic and other anxiety disorders has evolved over the years.

Sigmund Freud (1856-1939) distinguished anxiety from fear. He considered fear to be an expected response to a specific, identifiable trigger, whereas anxiety was a similar emotional state without an identifiable trigger. He postulated that anxiety resulted from unconscious, forbidden wishes that conflicted with what the person believed was acceptable. The anxiety that resulted from this mental conflict was called an “anxiety neurosis” and was thought to result in a variety of psychological and physical symptoms. Psychoanalysis was developed to uncover these hidden conflicts and to allow the anxiety to be released.

Freud’s theories about anxiety are no longer universally accepted. Many psychiatrists now believe that several anxiety disorders have a biological cause and that they are more neurological diseases than psychological ones. This is primarily true of generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder. It is recognized that anxiety can also be triggered by drugs (legal and illicit) and a variety of medical illnesses.

Psychological causes of anxiety are also recognized. Adjustment disorder with anxious mood, phobias, and post-traumatic stress disorder are all thought to be primarily psychological disorders. 

Unlike with Freud’s conflict theory of anxiety, most modern psychiatrists consider personality factors, life experiences, and views of the world to be the relevant psychological factors in such anxiety disorders. 

Nonpharmacological therapies are no longer designed to uncover hidden mental conflicts; they provide instead support. Specific therapies include flooding (massive exposure to the feared situation), systematic desensitization (graded exposure), and relaxation techniques.

For Further Information:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, D.C.: Author, 2000. This textbook contains the official diagnostic criteria and classification for all the anxiety disorders. Provides useful descriptions, definitions, and prevalence data.

Barlow, David H. Anxiety and Its Disorders. 2d ed. New York: Guilford Press, 2002. Examines the subject in the context of recent developments in emotion theory, cognitive science, and neuroscience. Reviews the implications for treatment and integrates them into newly developed treatment protocols for the various anxiety disorders.

Bourne, Edmond J. The Anxiety and Phobia Workbook. Oakland, Calif.: New Harbinger, 1995. This is an excellent self-help book for problems related to anxiety. It may also be helpful for family members seeking to understand anxiety better or to support those affected by anxiety.

Davidson, Jonathan, and Henry Dreher. The Anxiety Book. New York: Penguin, 2003. The director of the Anxiety and Traumatic Stress Program at Duke University Medical Center provides an informed overview of each category of chronic anxiety, including its symptoms and manifestations. Self-assessment tests are included to help readers identify which type of anxiety is troubling them.

Kleinknecht, Ronald A. Mastering Anxiety: The Nature and Treatment of Anxious Conditions. New York: Plenum Press, 1991. This book provides a good overview, with statistics and good explanations of the different types of anxiety disorder.

Leaman, Thomas L. Healing the Anxiety Diseases. New York: Plenum Press, 1992. A helpful text written by a family physician with an interest in anxiety disorders. Provides a good overview of the subject in nontechnical terms and contains practical advice on dealing with anxiety.

Saul, Helen. Phobias: Fighting the Fear. New York: Arcade, 2001. Traces the historical and cultural roots of phobias, examining case studies and literature in the process.

Sheehan, David V. The Anxiety Disease. New York: Bantam Books, 1983. A classic book written for the layperson that explains the nature of anxiety, the different types of anxiety disorder, and treatment approaches.

Note:  If you feel that you are having an Anxiety Attack and it is causing you to have physical manifestations, please seek medical assistance.  -Birdy