Anxiety Disorders

Dr. C. George Boeree

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[Note:  The quotes in italics below are from Mental Health:  A Report of the Surgeon General, U.S. Public Health Services (1999), available at http://www.surgeongeneral.gov/library/mentalhealth/home.html]

The anxiety disorders are the most common, or frequently occurring, mental disorders. They encompass a group of conditions that share extreme or pathological anxiety as the principal disturbance of mood or emotional tone. Anxiety, which may be understood as the pathological counterpart of normal fear, is manifest by disturbances of mood, as well as of thinking, behavior, and physiological activity.

Anxiety is at the root of many, if not all, of our psychological disorders.  It is, physically, a kind of fear response, involving the activation of the sympathetic nervous system, in response to a dangerous situation.  More specifically, anxiety is the anticipation of danger, learned through repeated stress or trauma.  Some people are innately more sensitive to stress, and so are more likely to experience anxiety and develop anxiety disorders.  But everyone becomes sensitized to stress and trauma with repeated experiences:  Each experience "tunes" the nervous system to respond more quickly and more profoundly to perceived danger.

We often talk about anxiety as some sort of genetic issue, and also as something based on traumas in childhood.  But long term stress is probably more often the root of anxiety disorders.  The constant demands of living in poverty, discrimination, war, and abuse are a part of daily life for millions of people around the world.

There are basically five ways in which people respond to unrelenting stress and trauma and the anxiety that comes with them:

1. Anxiety disorders - the subject of this section.
2. Self-medication, leading to alcoholism and other drug-dependencies.
3. Depression - shutting down (a common western response).
4. Somatization - bodily aches and pains (a common non-western response).
5. Dissociation - various "trance" states, and ultimately, psychosis.

Panic Attacks and Panic Disorder

A panic attack is a discrete period of intense fear or discomfort that is associated with numerous somatic and cognitive symptoms (DSM-IV). These symptoms include palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pain, nausea or gastrointestinal distress, dizziness or lightheadedness, tingling sensations, and chills or blushing and “hot flashes.” The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes. Most people report a fear of dying, “going crazy,” or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins and, when associated with chest pain or shortness of breath, frequently results in seeking aid from a hospital emergency room or other type of urgent assistance. Yet an attack rarely lasts longer than 30 minutes.

Panic disorder is about twice as common among women as men (American Psychiatric Association, 1998). Age of onset is most common between late adolescence and midadult life, with onset relatively uncommon past age 50.

Panic attacks are themselves traumatic, and so lead to increased anxiety, which makes the person more vigilant and more likely to misinterpret situations as well as bodily symptoms, and so have more panic attacks.  They are the classic example of anticipatory anxiety:  Being afraid of having a panic attack is the very thing that causes the panic attack!

Agoraphobia

The ancient term agoraphobia is translated from Greek as fear of an open marketplace. Agoraphobia today describes severe and pervasive anxiety about being in situations from which escape might be difficult or avoidance of situations such as being alone outside of the home, traveling in a car, bus, or airplane, or being in a crowded area (DSM-IV).

Most people who present to [are seen by] mental health specialists develop agoraphobia after the onset of panic disorder (American Psychiatric Association, 1998). Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and the subsequent worry, preoccupation, and avoidance (Barlow, 1988).

Agoraphobia occurs about two times more commonly among women than men (Magee et al., 1996).

Since 95% of agoraphobics also have panic disorder, perhaps the two categories are really only one.

Specific Phobias

These common conditions are characterized by marked fear of specific objects or situations (DSM-IV). Exposure to the object of the phobia, either in real life or via imagination or video, invariably elicits intense anxiety, which may include a (situationally bound) panic attack. Adults generally recognize that this intense fear is irrational. Nevertheless, they typically avoid the phobic stimulus or endure exposure with great difficulty. The most common specific phobias include the following feared stimuli or situations: animals (especially snakes, rodents, birds, and dogs); insects (especially spiders and bees or hornets); heights; elevators; flying; automobile driving; water; storms; and blood or injections.

Approximately 8 percent of the adult population suffers from one or more specific phobias in 1 year....  Typically, the specific phobias begin in childhood, although there is a second “peak” of onset in the middle 20s of adulthood (DSM-IV). Most phobias persist for years or even decades, and relatively few remit [improve] spontaneously or without treatment.

The specific phobias generally do not result from exposure to a single traumatic event (i.e., being bitten by a dog or nearly drowning) (Marks, 1969). Rather, there is evidence of phobia in other family members and social or vicarious learning of phobias (Cook & Mineka, 1989). Spontaneous, unexpected panic attacks also appear to play a role in the development of specific phobia, although the particular pattern of avoidance is much more focal and circumscribed.

Phobias can be understood in part as a matter of conditioned fear:  Strong anxiety or a panic attack is experienced at the same time as the phobic object, and so becomes associated with that object.  More often than not, the panic is not a response to the phobic object (snake, mouse, or spider), but rather to the loss of security experienced when someone (such as your mom or dad) responds dramatically to that object.  If mom or dad is scared, I should be really scared!

It also seems that many phobias have a strong built-in component.  Many people are at least uncomfortable, if not phobic, around snakes, mice, spiders, reptiles, dogs, heights, tight spaces, and swooping birds.  These things make us fearful even before we learn their potential danger.  These fears do make some sense, if you consider the dangers these could have posed for our ancient ancestors.  Of course, it is not the figure of a bird, a snake, a spider, or a dog that directly leads to the fear response.  It is rather the swooping motion, the slithering, the unpredictable presence, the low growling noises, and so on.

Social Phobia

Social phobia, also known as social anxiety disorder, describes people with marked and persistent anxiety in social situations, including performances and public speaking (Ballenger et al., 1998). The critical element of the fearfulness is the possibility of embarrassment or ridicule. Like specific phobias, the fear is recognized by adults as excessive or unreasonable, but the dreaded social situation is avoided or is tolerated with great discomfort. Many people with social phobia are preoccupied with concerns that others will see their anxiety symptoms (i.e., trembling, sweating, or blushing); or notice their halting or rapid speech; or judge them to be weak, stupid, or “crazy.” Fears of fainting, losing control of bowel or bladder function, or having one’s mind going blank are also not uncommon. Social phobias generally are associated with significant anticipatory anxiety for days or weeks before the dreaded event, which in turn may further handicap performance and heighten embarrassment.

Social phobia is more common in women (Wells et al., 1994). Social phobia typically begins in childhood or adolescence and, for many, it is associated with the traits of shyness and social inhibition (Kagan et al., 1988). A public humiliation, severe embarrassment, or other stressful experience may provoke an intensification of difficulties (Barlow, 1988). Once the disorder is established, complete remissions are uncommon without treatment. More commonly, the severity of symptoms and impairments tends to fluctuate in relation to vocational demands and the stability of social relationships.

Social phobia is another example of anticipatory anxiety:  The expectation of social embarrassment causes the anxiety that leads to social embarrassment...  In the U.S., social phobia often begins in early adolescence, when peers often humiliate shy children.  This is common in any highly competitive society like ours.  Also, people in lower social positions in a very hierarchical society (and yes, ours is one) often find themselves victimized this way, and developing social phobia.

In Japan, there is an interesting variation on social phobia called taijin kyofusho.  This involves great anxiety that other people find your appearance, your face, and even your odor offensive.

Generalized Anxiety Disorder

Generalized anxiety disorder is defined by a protracted (> 6 months’ duration) period of anxiety and worry, accompanied by multiple associated symptoms (DSM-IV). These symptoms include muscle tension, easy fatiguability, poor concentration, insomnia, and irritability....  [T]he excessive worries often pertain to many areas, including work, relationships, finances, the well-being of one’s family, potential misfortunes, and impending deadlines. Somatic anxiety symptoms are common, as are sporadic panic attacks.

Generalized anxiety disorder occurs more often in women, with a sex ratio of about 2 women to 1 man (Brawman-Mintzer & Lydiard, 1996). The 1-year population prevalence is about 3 percent (Table 4-1). Approximately 50 percent of cases begin in childhood or adolescence.

In Latin America, some people suffer from something called nervios ("nerves").  They feel a great deal of anxiety, insomnia, headaches, dizziness, even palpitations.  It usually begins with a loss of someone close, or with family conflicts.  Since family is everything in many cultures, family problems are often at the root of psychological problems.

Acute and Post-Traumatic Stress Disorders

Acute stress disorder refers to the anxiety and behavioral disturbances that develop within the first month after exposure to an extreme trauma. Generally, the symptoms of an acute stress disorder begin during or shortly following the trauma. Such extreme traumatic events include rape or other severe physical assault, near-death experiences in accidents, witnessing a murder, and combat. The symptom of dissociation, which reflects a perceived detachment of the mind from the emotional state or even the body, is a critical feature. Dissociation also is characterized by a sense of the world as a dreamlike or unreal place and may be accompanied by poor memory of the specific events, which in severe form is known as dissociative amnesia [loss of memory not based on physical causes]. Other features of an acute stress disorder include symptoms of generalized anxiety and hyperarousal, avoidance of situations or stimuli that elicit memories of the trauma, and persistent, intrusive recollections of the event via flashbacks, dreams, or recurrent thoughts or visual images.

By virtue of the more sustained nature of post-traumatic stress disorder (relative to acute stress disorder), a number of changes, including decreased self-esteem, loss of sustained beliefs about people or society, hopelessness, a sense of being permanently damaged, and difficulties in previously established relationships, are typically observed. Substance abuse often develops, especially involving alcohol, marijuana, and sedative-hypnotic drugs.

About 50 percent of cases of post-traumatic stress disorder remit within 6 months. For the remainder, the disorder typically persists for years and can dominate the sufferer’s life. A longitudinal [long-term] study of Vietnam veterans, for example, found 15 percent of veterans to be suffering from post-traumatic stress disorder 19 years after combat exposure (cited in McFarlane & Yehuda, 1996). In the general population, the 1-year prevalence is about 3.6 percent, with women having almost twice the prevalence of men (Kessler et al., 1995) (Table 4-1). The highest rates of post-traumatic stress disorder are found among women who are victims of crime, especially rape, as well as among torture and concentration camp survivors (Yehuda, 1999).

PTSD appears to involve a number of problems with the hippocampus which, if you recall, is devoted to moving short-term memories into long-term storage.  First, intensely emotional events lead to intense memories called flashbulb memories.  It seems that these memories may actually be partially stored in the amygdala, which accounts for the fearfulness involved.  In addition, the prolonged stress of experiences such as war or childhood abuse actually begins to destroy tissue in the hippocampus, making it more difficult to create new long term memories.  Studies show that people who have suffered long-term trauma have anywhere from 8 to 12% less hippocampus.  The net result could be that they are, in a sense, stuck in their traumatic past.

PTSD is an example of an anxiety disorder that also involves some of the other responses to trauma I mentioned above.  Many self-medicate with alcohol and drugs, only making the problem worse.  Many are severely depressed.  There is also a degree of dissociation involved, meaning that victims become numb, detached, showing little emotion.  They no longer feel real.  Perhaps this is actually an adaptive response to traumatic stress.  We find this kind of dissociation commonly in refugee populations, who can sometimes seem like zombies.  They may simply be protecting themselves from further psychological pain.

Obsessive-Compulsive Disorder

Obsessions are recurrent, intrusive thoughts, impulses, or images that are perceived as inappropriate, grotesque, or forbidden (DSM-IV). The obsessions, which elicit anxiety and marked distress, are termed “ego-alien” or “ego-dystonic” because their content is quite unlike the thoughts that the person usually has. Obsessions are perceived as uncontrollable, and the sufferer often fears that he or she will lose control and act upon such thoughts or impulses. Common themes include contamination with germs or body fluids, doubts (i.e., the worry that something important has been overlooked or that the sufferer has unknowingly inflicted harm on someone), order or symmetry, or loss of control of violent or sexual impulses.

Compulsions are repetitive behaviors or mental acts that reduce the anxiety that accompanies an obsession or “prevent” some dreaded event from happening (DSM-IV). Compulsions include both overt behaviors, such as hand washing or checking, and mental acts including counting or praying. Not uncommonly, compulsive rituals take up long periods of time, even hours, to complete. For example, repeated hand washing, intended to remedy anxiety about contamination, is a common cause of contact dermatitis [a common skin disease].

Although once thought to be rare, obsessive-compulsive disorder has now been documented to have a 1-year prevalence of 2.4 percent (Table 4-1). Obsessive-compulsive disorder is equally common among men and women.

Obsessive-compulsive disorder typically begins in adolescence to young adult life (males) or in young adult life (females)....  Approximately 20 to 30 percent of people in clinical samples with obsessive-compulsive disorder report a past history of tics, and about one-quarter of these people meet the full criteria for Tourette’s disorder (DSM-IV).

Obsessive-compulsive disorder has a clear familial pattern and somewhat greater familial specificity than most other anxiety disorders. Furthermore, there is an increased risk of obsessive-compulsive disorder among first-degree relatives with Tourette’s disorder. Other mental disorders that may fall within the spectrum of obsessive-compulsive disorder include trichotillomania (compulsive hair pulling), compulsive shoplifting, gambling, and sexual behavior disorders (Hollander, 1996).

We are beginning to understand some of the brain activities associated with OCD .  The caudate nucleus (a part of the basal ganglia near the limbic system) is responsible, among other things, for urges, including things like reminding you to lock doors, brush your teeth, wash your hands, and so on.  It sends messages to the orbital area (above the eyes) of the prefrontal area, which tells us that something is not right.  It also sends messages to the cingulate gyrus (just under the frontal lobe), which keeps attention focused, in this case on the feeling of something not being right and needing to be done.  It is believed that, in people with OCD, this system is stuck on "high alert."

It should be noted that OCD responds fairly well to the same medications (such as Prozac) that help people who are depressed, which suggests that the seratonin pathways of the frontal lobe and limbic system are involved, just as they are with depression.  More recently, scientists have discovered several genes that appear to be strongly tied to OCD.

But don't think OCD is a purely physiological disorder!  It varies a great deal from culture to culture.  In some cultures, the behaviors are even seen as positive.  Remember that there are still all kinds of superstitious behaviors that people engage in today, which are no different from compulsions.  And, while being obsessed with, say, germs is considered odd, being obsessed with, say, football is considered perfectly okay in our culture!

We might also include hypochondriasis here (even though it is "officially" classified as a somatoform disorder).  People with hypochondriasis (called hypochondriacs) are preoccupied with fears of having or getting a serious disease.  Even after being told that they do not have the disease they are concerned about, they continue to worry.  They often exaggerate minor abnormalities, go from doctor to doctor, and ask for repeated examinations and medical tests.  A guess at prevalence of hypochondriacs is that it involves between 4% and 9% of the population.

A curious version of hypochondriasis is found in India, called dhat.  People with dhat suffer from anxiety, fatigue, aches, weakness, depression, and so on - all revolving around an obsessive concern with having lost too much semen!  We may laugh, but 100 years ago, westerners also believed that a man has only so much semen to use in his life-time, and 50 years ago, coaches would warn their players not to have sex the night before a big game because it would drain them of energy.  In the U.S. today, people are obsessed with aging to such a degree that they are willing to undergo surgery and injections of poisons to appear younger - even though these activities may actually decrease their life-span!

Three other disorders are related to obsessive-compulsive disorder (although officially categorized as impulse-control disorders):

Trichotillomania is the “recurrent pulling out of one’s hair for pleasure, gratification, or relief of tension that results in noticeable hair loss.” (DSM IV)   It is not restricted to hair on head, and may even involve pulling out eyelashes.  Trichotillomania is often associated with stress, but sometimes occurs while the person is relaxed as well.  It usually starts in childhood or adolescence.  1 to 2% of college students report having had trichotillomania at some time.

Kleptomania is the “recurrent failure to resist impulses to steal objects not needed for personal use or monetary value.”  (DSM IV) The person knows it is wrong, fears being caught, and feels guilty about it, but can’t seem to resist the impulse.  It is rare, but much more common among women than among men.  It is, as you can imagine, difficult to differentiate from intentional stealing!

Pathological gambling is “recurrent and persistent maladaptive gambling behavior.”  (DSM IV)  We often call it compulsive gambling.  A lot of distorted thinking goes with it -- superstition, overconfidence, denial.  Pathological gamblers tend to be people with a lot of energy who are easily bored, and the urge to gamble increases when they are under stress.  It may involve 1 to 3% of the population, and two thirds are men.