The disabling effects of anxiety disorders
Anxiety disorders are a group of different conditions with anxiety as their common core. Recent studies have exposed the surprising prevalence of anxiety disorders in modern society, a hidden epidemic now known to affect over 10 per cent of North Americans at some point in their lives. The word anxiety comes from the Greek “to constrict,” capturing the strong physical sensations of tightness prominent in anxiety disorders.
Distinguishing normal anxiety from true anxiety syndromes Some anxiety is a normal part of human existence, but if it is debilitating enough to undermine everyday activities it may be a clinical anxiety disorder. There is a profound difference between normal anxiety as a protective human response and anxiety as a psychiatric disorder. Fear is a normal, biologically adaptive reaction to real danger. By contrast, unfounded or unrealistic anxiety is a maladaptive, vague fear of hostility, of danger “around every comer” even when there’s no real threat. Whether or not any real danger exists, fear arouses the body’s autonornic (involuntary) nervous system. It evokes the “flight or fight” response, accelerating the heartbeat, preventing sleep and putting all senses on the alert. The hormone, norepinephrine, dilates the pupils, increases sweating, makes the hair stand on end and diverts blood to the working muscles. In anxiety disorders there is a similar but uncalled-for “flight-fight” response, triggering norepinephrine production when there’s nothing to fight or flee from. Anxiety that’s disproportionate to reality can become a serious health problem. Human beings will not endure intense anxiety for long without feeling ill or developing a “phobic” avoidance of the fear-arousing situations or events. If anxiety abolishes the ability to function normally, it requires professional help. Unresolved or untreated anxiety problems may lead to clinical depression, alcoholism and suicidal tendencies.
Anxiety disorders include:
* panic disorder;
* generalized anxiety disorder (GAD);
* post-traumatic stress disorder (PTSD);
* simple phobia;
* social phobia;
* obsessive-compulsive disorder (OCD).
NB: Although each anxiety disorder is distinct, with its own set of symptoms, different forms can coexist.
Anxiety disorders more disabling that hitherto recognized
All of us fret to a certain extent about everyday problems. And because some nervousness is a normal part of life, clinical anxiety disorders tend to be trivialized, often go undiagnosed and are considered less troublesome than other psychiatric conditions. A recent University of Toronto study showed that many who suffer from anxiety syndromes are misdiagnosed, get extensive cardiac or neurological work-ups and perhaps faulty treatment because of failure to recognize an anxiety disorder that might have responded to simple therapy. Yet true anxiety disorders are far from trivial. They can destroy careers, families and friendships. The life of someone with post-traumatic stress disorder (following a life-threatening assault) or of an obsessive-compulsive may be almost as disrupted as that of a schizophrenic. A 1988 American National Institute of Mental Health survey of more than 18,000 people in five U.S. cities astonished the psychiatric community by revealing that anxiety disorders are now the most prevalent psychiatric illness in North America.
The largest survey of psychiatric problems ever undertaken, the study found the six-month prevalence of anxiety disorders among the population to be 7.3 per cent, with 14 per cent of respondents reporting transient anxiety problems at some time in their lives. (By contrast, the prevalence of alcohol and drug abuse was 3.8 per cent, schizophrenia 0.6 per cent and major depression 2.2 per cent.)
Anxiety can also accompany other psychiatric illnesses and medical conditions such as thyroid disease, asthma, heart ailments and gastric problems. Some drugs, licit and illicit – for instance, caffeine, cocaine, bronchodilators and amphetamines -cause anxiety-like symptoms. Surveys show that many patients in general practice units (one quarter of patients, according to some studies) have transient panic attacks in certain situations or due to drugs such as marijuana or cocaine. Occasional panic attacks or those linked to drug use do not constitute true anxiety disorder. Anxiety symptoms may mimic those of medical conditions – such as shortness of breath (as in asthma), chest pain (as in heart disease), diarrhea (as in bowel disorders) – an added reason for incorrect diagnosis.
General treatment for relieving anxiety disorders Whatever the cause(s) of anxiety disorders, treatment usually entails psychological counselling, behaviour or cognitive therapy and sometimes medications. The link between the underlying anxiety and physical symptoms such as chest pain (without any identifiable heart problem) or gastro-intestinal upsets (for no known reason) must be clearly pointed out. It’s best to start therapy as soon as the anxiety becomes significantly disrupting. For many, the most frightening part is the dread of some terrible disease and not understanding that the anxiety symptoms in themselves are harmless – that there’s no incipient heart failure or other illness on the horizon. Realizing how the brain triggers anxiety, knowing that it won’t kill you can allay fear. Many seem to cope once they have a clear scientific explanation of the condition and know they don’t have some life-endangering disease. Those whose anxiety is related only to a few situations can often get by without professional aid. For example, someone who is afraid of public speaking faces no anxiety problem unless forced to address large groups (such as politicians or criminal lawyers). A woman who’s afraid of dogs will be fine unless she is a veterinarian or marries someone who adores dogs. However, obsessive hand-washers who peel off their skin or agoraphobics too afraid to leave the house need intensive therapy. Specific behaviour therapy is often very effective. A good therapist assesses the reasons for anxiety, traces events that might have triggered it and evaluates its impact on everyday activities.
Exposure therapy, becoming increasingly popular, can quickly relieve some anxiety disorders, especially phobias. It helps people confront the fear-evoking situation(s), enabling them to develop coping mechanisms that extinguish the anxiety. For example, a spider-fearing arachnophobic might be asked first to look at pictures of spiders, then to keep a spider in a cage at home, then in the bedroom, until the discomfort subsides. An agoraphobic may be taken on subway rides, exposed to busy streets or asked to spend hours in a shopping mall. For social phobics, the therapist might role-play the fear-arousing situation (e.g., dating or speaking at a wedding) to build strength. Exposure therapy may swiftly abolish the anxiety or it may take several sessions, each lasting a few hours.
Cognitive therapy means understanding the reason(s) for anxiety, helping sufferers rationally reappraise the maladaptive beliefs which make the person feel defenceless and “forced to flee.” The catastrophic thought mode – expectation of dreadful things that might happen – is replaced with logical patterns to break the cycle.
Pharmacotherapy employs anxiety-relieving medications or anxiolytics, for instance the benzodiazepines, such as alprazolam, clonazepam or lorazepam. But many anxious people are reluctant to take such drugs for fear of dependence or addiction. However, addiction is very unusual in people taking benzodiazepines for anxiety. The benzodiazepines are usually given for two to six months, not generally for long-term therapy unless severe symptoms warrant continued use. Withdrawal symptoms of rebound anxiety, insomnia and tremors can be a problem when discontinuing benzodiazepines. It’s best to taper down dosages gradually. Other useful anti-anxiety medications include the antidepressants (such as imipramine or desipramine) and fluoxetine, often used for longer term therapy.
Panic disorder in particular
The word “panic” comes from the Greek god, Pan, who used to jump at passers-by as a practical joke. But panic disorder is no laughing matter. Panic attacks may come “out of the blue” as episodes of terror that hit for no discernible reason, often beginning in the teens or early adulthood. Previously mislabelled “housewives’ disease” or “soldier’s heart,” panic attacks can immobilize people from all walks of life. Depending on the particular symptoms and the person’s interpretation of them, panic-ridden people may think they’re having a heart attack or some other disease. The typical symptoms – chest pain, shortness of breath and a sense of choking – send many rushing to the hospital emergency with the first few episodes. (The chest tightness is due to the anxiety, not a cardiac problem.) Other symptoms include palpitations, flushing, chills, sweating, difficulty swallowing, dizziness, unsteadiness, feelings of unreality and a sense of incapacity. During a panic attack, many feel strangely disconnected from their surroundings. Some think they are going to die or go mad. If panic attacks continue, people begin to wonder whether they’re crazy, comments one University of Toronto specialist. “They may imagine it’s due to something they did or that there is something about the situation during which the attacks happen that somehow triggered them. In trying to come up with answers, many misattribute the cause of panic attacks to the context in which they arose.” For example, someone who had an attack while driving a car may believe there is something about driving or their destination that caused the panic. Panickers who link attacks with the situations in which they occur may avoid more and more places, developing an increasingly constricted lifestyle, sometimes becoming completely housebound. Yet those beset by panic attacks may not seem outwardly agitated, just quietly describe the terrifying episodes.
A U.S. National Institute of Health report notes that many anxious patients see 10 or more doctors before their condition is accurately pinpointed and properly treated. Panic attacks may star1 during major life changes and in some cases therapists can piece together a psychosocial picture that triggered the attacks -such as a divorce, a death in the family, stress or excess work. Some people who function alright during the stressful event(s) panic when things calm down. Some have panic attacks mostly at night, others more in the daytime. Some experience several attacks a day – very unnerving. A typical panic attack lasts for two to 10 minutes, sometimes up to an hour. Even when the attack is over, anxiety can linger on for hours or days.
The DSM-III Psychiatric Manual defines panic disorder as “one or more panic attacks per week for four weeks or one or more followed by persistent fears of panic.” In order to qualify as panic disorder some attacks must be spontaneous and unexpected, not triggered by a definite event such as an exam or sighting a snake. Since alcohol may relieve the panic, not surprisingly some panickers (about a third) become alcoholics. Panic disorders may also result in depression and suicide.
Treatment for panic attacks is the same as for most anxiety problems – behaviour therapy. knowledge of what’s going on in the person’s life and reassurance that disease or death aren’t imminent. Many panickers calm down once they know that the condition likely stems from a biochemical imbalance in the brain which is not life-threatening. Psychotherapy and medications such as benzodiazepines, antidepressants or fluoxetine are usually effective.
Simple phobias, among the commonest of anxiety disorders, entail persistent, irrational fear (sometimes amounting to panic) of circumscribed events or situations. Among the countless specific phobias the most frequent are: fear of animals (such as dogs, snakes, mice), fear of heights, blood, crowds, enclosed spaces, lightning or air travel. More unusual phobias include: arachnophobia (fear of spiders), photophobia (fear of light), sarcophagophobia (fear of being buried alive) and apiphobia (fear of bees). Phobias are more common in women than men and often begin around ages seven to nine, the childhood fears of lightning, dogs or whatever persisting through life. Many phobic people prefer to hide their phobias, just avoiding the specific triggers unless circumstances force them to be in repeated contact with the feared situation – as with politicians afraid of air travel – when therapy may be sought.
Treatment is with exposure therapy, which often works well. Sometimes a single therapy session lasting a few hours may eradicate the phobia. For example, one woman terrified of cats was confronted with a small cat in her therapy session, stood trembling by the door for 40 minutes, gradually came nearer, touched the cat on the therapist’s lap and at the end of a four-hour session ended up with the cat on her lap, the phobia gone.
More common in men than women, social phobia is the fear of performing, of being scrutinized by peers or by the public, of “not being liked.” Fearing evaluation, the social phobic blushes, trembles, feels faint and may be totally unable to perform. Social phobias typically revolve around speaking in public, going to restaurants, using public washrooms or signing one’s name in front of a bank teller (for fear of a trembling hand and wobbly signature!). Often beginning in adolescence, social phobias affect about two per cent of the population. The inhibition or shyness can cripple social and professional life, possibly resulting in alcoholism and depression. For example, an eight-year-old boy who can’t speak up in class may skip school; a lawyer unable to address the jury without trembling may change careers; an advertising creator, afraid to present his ideas, may turn to writing copy for others; or someone asked to join the head table at a banquet may refuse for fear those watching would see his inability to swallow.
Therapy may include MAOI anti-depressants (e.g., phenelzine, tranylcvpromine). For those with stage fright, beta blockers or benzodiazepines taken just before a performance may reduce the anxiety.
Generalized anxiety disorder
Less debilitating than panic disorder, generalized anxiety disorder (GAD) is a distressing complaint with free-floating anxiety and jitteriness, not usually crystallized into discrete panic episodes. General anxiety often masquerades or manifests itself as physical symptoms with no anatomical or identifiable basis – such as tension (trembling, twitching, restlessness), gastric upsets, urinary problems, chest pain, headaches, autonomic system overactivity (dizziness, sweating, palpitations) and hypervigilance (being perpetually keyed up). GAD sufferers often report pervasive fatigue, insomnia and an inability to fall asleep. To qualify as GAD, symptoms must be prominent for six months or longer. GAD affects two to five per cent of the population, more women than men. The disorder resembles panic, but people with GAD get worried about far less severe symptoms than true panickers, often consulting physicians not only about physical ailments, but to discuss unrealistic worries such as anxiety over a perfectly well child’s health, worry over money (when there are no financial problems), or fear of losing a job when there is no cause for concern.
Treatment for generalized anxiety disorder is psychotherapy and medication plus reassurance that it’s not a deadly disease. GAD sufferers often recover once they realize that the physical manifestations stem from underlying anxiety and that lifestyle changes might solve the problem – for example more rest periods, exercise and holidays. Buspirone, a new medication, with fewer side-effects and less habit-forming potential than other anxiety-reducing medications, is useful.
Post-traumatic stress disorder (PTSD)
This anxiety condition arises after some overwhelming, life-threatening trauma such as rape, assault, car accidents, plane crashes, war, torture, imprisonment or natural disasters such as earthquakes or floods. Its prevalence and severity are often under-estimated. “Shell shock” was the expression used for World War I veterans where post-traumatic stress disorder was first documented. It is frequent among U.S. Vietnam combat veterans, as many as 50 per cent of those engaged in heavy combat apparently suffering from it. A University of Toronto study showed that 50 years later, many World War II concentration camp survivors, especially those from Auschwitz still suffer severe PTSD. Its striking features are recurrent nightmares, flashbacks of the traumatic event and intense anxiety on exposure to any reminders – such as helicopters for Vietnam veterans and news bulletins or anti-Israeli propaganda for Nazi concentration camp survivors. Those with PTSD may have numbing emotional detachment, recurrent insomnia, an exaggerated startle response (jumpiness) and profound guilt over having survived when others perished. The prevalence of post-traumatic disorder in the North American population is one per cent, some of it due to the traumas of modern life – especially car crashes and assaults.
Treatment for PTSD is psychotherapy to dispel the terrifying flashbacks, plus tricyclic antidepressants (such as imipramine) or MAOI antidepressants. But despite treatment many with PTSD continue to suffer great distress.
Once regarded as a psychiatric curiosity, obsessive-compulsive disorder or OCD is now proving to be very common, affecting as many as one in 50 North Americans. After a flurry of media interest, evoked by 1980s TV talk shows publicizing the usefulness of the drug buspirone for treating OCD, many came out of the closet to reveal their strange, sometimes bizarre, often secret behaviours. Obsessive-compulsives whose behaviour had nearly wrecked their lives told fellow sufferers how therapy had helped them. Similarly, when columnist Ann Landers wrote about OCD she was deluged with 8,000 letters in one week.
Many with OCD try to hide their obsessive behaviour even from family and close friends. Sigmund Freud noted that obsessives are adept at concealment because, having devoted several hours to their “secret doings,” they function well for the rest of the day. The secret doings that Freud describes are rituals, performed to relieve the anxiety caused by obsessive thoughts. A person who touches every lamppost, chews every mouthful hundreds of times, must brush the hair 200 times, spends hours opening and closing cupboards or is afraid to use the toilet (for fear of germs), may resemble a schizophrenic. But unlike psychotics, who believe their thoughts come from outside sources – from aliens or devils – obsessives know that their thoughts are their own and consider their actions pointless, one reason why they’re kept secret. Despite the realization that their fears are unfounded, obsessives still give in to them. A well known journalist feels compelled to check that her front door is closed 10 times every morning before going work. One internist calls the lab a dozen times to make sure the test results are right, noting that his compulsion seems “senseless,” but he still feels obliged to call. Some OCD sufferers stretch a routine activity like dressing from minutes to hours. Some feel compelled to go from the car to the front door in a certain way – four steps forward, two back, or singing “Yankee Doodle Dandy” (to the despair of their families and possible amusement of neighbours).
On a less significant level, mild obsessions can simply be a rigid way of doing things. For example, some ultra-neat people can’t sleep until every dinner dish has been cleared, all ashtrays emptied or crooked paintings straightened. Such eccentrics do not necessarily have OCD. People with OCD are not merely fussy or meticulous, nor are they neurotics. They know their actions are counterproductive, struggle to resist them, describe their behaviour as “dumb,” but are convinced that if they don’t continue the rituals something bad will befall themselves or others. The American Psychiatric’ Association describes OCD as an illness with recurrent obsessions or compulsions, or both, severe enough to cause marked distress, be time-consuming (over one hour a day) or interfere significantly with normal routine. The obsessive thoughts are deeply disturbing, not pleasurable. In severe cases, the thoughts become so tormenting that the person sacrifices relationships, work, school and basic comfort to escape them. In some instances obsessives do nothing else all day except attend to their rituals.
OCD tends to emerge in adolescence through to the mid-thirties, although it can start in childhood. Fear of contamination is a common theme, many obsessives being afraid to shake hands or touch doorknobs because of dirt or to eat for fear of poisoning. Other obsessives fear loss of control, are afraid of strangling their children or killing a dog. Some have disturbing sexual thoughts, tormenting fantasies, blasphemous images, pathological doubts or concerns about sin or hell. Families often worry that the person with OCD might act out hostile obsessions, but obsessives want to avoid their thoughts not derive pleasure from them. OCD patients very rarely act out violent thoughts.
Common types of obsessives:
“Cleaners” (85 per cent of those with OCD) in whom fear of contagion compels many to wash their hands 50 or 60 times a day, often with harsh soaps until the hands are raw, or spend hours in the shower. Although the obsessive knows that the dread of filth is irrational, the thoughts create such psychic distress that they must be relieved by constant cleansing. Washing eases the tension but the distress builds up again until the cleaning must start over.
“Checkers” (doubters) are compelled to continually re-check their actions – for instance to make sure they have turned off the stove or locked the door. Some repeatedly visit the scene of an imagined accident to be certain they haven’t run over a child on the way home. “They are reassurance addicts,” comments one therapist, “constantly checking to make sure nothing’s amiss.”
“Hoarders” may save every piece of mail they’ve ever received and every scrap of paper, even Christmas trees from past years -for fear that they’ll throw out something valuable.
* fears of contamination: “Everything I touch is full of germs.”
* doubt: “Did I hit that dog with my car?”
* orderliness: “I can’t attend class until everything in my room is in perfect order.”
* fear of aggression toward oneself or others: “If I had a knife, I might lose control and stab my mother,” necessitating compulsive acts to make sure the violence cannot happen (e.g., throwing out all sharp objects).
OCD was traditionally viewed as a psychological disorder, attributed to restrictive parenting, early toilet training (causing an unhealthy obsession with cleanliness) or anxiety over sexual urges. But modern scientists believe it to be some biological abnormality, probably an imbalance in one or more neurotrans-mitters (chemicals that act as messengers between nerve cells)-particularly serotonin, which modulates repetitive actions, sleep, aggression and animal grooming behaviour. There may be too little serotonin in some areas of OCD brains, causing “grooming behaviour out of control.” The fact that one third of OCD cases improve with serotoninergic drugs (which raise serotonin levels) emphasizes this possibility.
Treatment for obsessive-compulsive disorder is with psychotherapy, antidepressants and new serotonin-activating drugs such as clomipramine (Anafranil), fluoxetine (Prozac) and fluvoxamine (Luvox). Hailed as a breakthrough, these agents may take six to 10 weeks to become effective. Since the medications suppress symptoms rather than curing the illness, the disorder may re-emerge if the drugs are discontinued. In serious cases, several drugs may be needed. However, OCD is a complex disorder, and therapy is not a matter of handing out a few pills and expecting lifelong horrors to vanish overnight. Many OCD sufferers have devoted hours each day to their obsessions for years, and it takes a great deal of psychotherapy to eradicate such deep-rooted behaviour.
Behaviour therapy employs “exposure” and “response prevention” exposing patients to the feared situations to reduce the rituals. In some studies, these methods are as effective as medication. Behavioural techniques provide relief to about 50-70 per cent of patients. The therapist guides OCD sufferers to confront the situation being avoided, such as touching door handles, shaking hands or eating certain foods, helping them to refrain from the ritualistic practices. Someone who detests dirt for instance, will be asked to rub dirt on the hands and abstain from handwashing for a while. Alternatively, the person might be encouraged to visualize the anticipated catastrophe, such as running over a cat, become accustomed to the thought and extinguish the anxiety. In the most severe cases, when OCD makes life unlivable, brain surgery may be a last resort.
For further information or help: contact Anxiety Disorder Clinics (eg., at Toronto’s Clarke Institute), or the Freedom From Fear Foundation (416) 761-6006.
Understanding how anxiety builds: tracing the causes
Anxiety disorders usually first appear in adolescence or early adulthood and often persist for life. They were once ascribed to “separation anxiety” (being separated from parents). castration anxiety, punitive parenting or conflict. Nowadays however. many researchers view anxiety disorder as a probable biological abnormality involving an overactive nervous system with specific imbalances in the brain’s neurotransmitters. Some experts believe that biochemical plus psychological, cognitive, behavioural. social and cultural factors jointly produce anxiety disorders. Finding the trigger(s) for anxiety problems is nol easy but in about half the cases therapists can piece together a scenario that, at least partly, accounts for the disorder. Many sufferers can identify stressors such as a family loss or conflict with an “important other” that precipitated the problem. (The psychological triggers may of course work through neurochemical brain messages.)
Agoraphobia-often linked to panic attacks
Agoraphobia, literally meaning tear of the “agora” or marketplace is the terror of being away from a safe place or being somewhere from which escape is difficult. Agoraphobics typically develop a fear of driving. tunnels, bridges shopping malls and subways. “What underlies the fear,” says one expert, “is being in a place or situation where they can’t get immediate help in case of a sudden panic attack. At its most extreme. agoraphobics won’t even leave the house because of the terror expected.” Agoraphobia is often linked to or follows panic attacks or it may arise independently. The agoraphobic fear may relate to specific places. Thus, if a woman was in the laundromat when she first experienced panic, she might be reluctant to go into any laundromat. Treatment for agoraphobia is similar to thai for panic disorder – psychotherapy. reassurance and perhaps the newer anxiolytic’ drugs e.g., clonazepam (Rivotril). Tricyclic antidepressants. monoamine oxidase inhibitors (MAOIs), beta blockers and fluoxetine can also relieve agoraphobic fear.
COPYRIGHT 1992 Strategic Inc. Communications Ltd.
COPYRIGHT 2008 Gale, Cengage Learning