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Anxiety and anxiety disorders


From: Anxiety disorders: An information guide ( © 2005, 2009 CAMH )
 
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Everyone feels anxiety from time to time. Few people get through a week without some anxious tension or a feeling that something is not going to go well. We may feel anxiety when we’re facing an important event, such as an exam or job interview, or when we perceive some threat or danger, such as waking to strange sounds in the night. However, such everyday anxiety is generally occasional, mild and brief, while the anxiety felt by the person with an anxiety disorder occurs frequently, is more intense, and lasts longer—up to hours, or even days.
Unfortunately, anxiety disorders are common. Research shows that up to one in four adults has an anxiety disorder sometime in their life, and that one person in 10 is likely to have had an anxiety disorder in the past year. Anxiety disorders are the most common mental health problem in women, and are second only to substance use disorders in men. Anxiety disorders can make it hard for people to work or study, to manage daily tasks and to relate well with others, and often result in financial strain and profound personal suffering.
People often live with anxiety disorders for years before they are diagnosed and treated. If you suspect that you have an anxiety disorder, it is important to seek professional treatment as soon as possible. Anxiety disorders are treatable, and early treatment can help to ensure treatment success.
The six main categories of anxiety disorders are phobias, panic disorder (with or without agoraphobia), generalized anxiety disorder, obsessive-compulsive disorder, acute stress disorder and posttraumatic stress disorder (American Psychiatric Association [APA], 2000). Each of these anxiety disorders is distinct in some ways, but they all share the same hallmark features:
  • irrational and excessive fear
  • apprehensive and tense feelings
  • difficulty managing daily tasks and/or distress related to these tasks.
In the following examples, Susan, John and Linda* show these common features, although the precise nature of their fears differ.
Susan has had recurrent and unexpected panic attacks for the past five years:
It started on a night when I was driving home in the rain. I began to feel shaky and dizzy, and had trouble focusing. At first, I thought it was something that I had eaten earlier, but then my mind started to drift, and I thought, “What if I pass out?” and “What if I’m dying?” I started to shake all over, and it was as if my entire body was wired. I quickly pulled the car over and called my daughter to come and get me. Since then, I’ve had dozens and dozens of these attacks. At first, the attacks occurred just when I was driving, but now I experience them in shopping malls, standing in line-ups and even on the bus. It seems as if I spend most of my day worrying and waiting for the next attack.
John describes a lifelong pattern of being excessively shy and fearing embarrassment in social situations:
For as long as I can remember, and as far back as when I was seven years old, I hated being the centre of attention. In class, I tried to remain as invisible as possible, praying that the teacher would not call upon me to answer a question. When it was my turn to make presentations, I wouldn’t sleep for a week, worrying that I would forget what I was supposed to say, stumble over my words, and look completely stupid. It’s as if nothing’s changed: now at work I dread having to attend meetings, meet with the boss, have lunch with colleagues, and the worst, give monthly reports to the team. I’m pretty sure everyone knows how uncomfortable I am, and they all probably think I look weird and sound stupid.
Linda, a 34-year-old married woman, has struggled with doubting obsessions and checking compulsions since she was 15. She describes her current problems:
I am worried that unless I take every precaution necessary to prevent harm, I am going to be responsible for something terrible happening. I have to check, recheck, check again, return to check, continue checking—the kitchen stove, the lights, the iron, my curling iron, the TV cable—to ensure that I don’t cause a fire. Then, when I’m about to leave the house, it starts with the door locks: check once, check twice, check again, maybe leave, get halfway to work and return to check again, to be 100 per cent sure that I did not leave the door open. At work, I can start, correct and restart a simple e-mail to the boss 20 times to make sure that I don’t say the wrong thing.
To better understand the nature of anxiety disorders such as those experienced by Susan, John and Linda, we need to first explore the nature of “normal” anxiety. Later in this chapter, we’ll describe the key fears and components of each major anxiety disorder.
*All names and identifying details have been changed.

What is normal anxiety?

A certain amount of anxiety is normal and necessary; it can lead you to act on your concerns and protect you from harm. In some situations, anxiety can even be essential to your survival. If you were standing at the edge of a curb, for example, and a car swerved toward you, you would immediately perceive danger, feel alarm and jump back to avoid the car. This normal anxiety response, called the “fight or flight” response, is what prompts you to either fight or flee from danger.
When we feel danger, or think that danger is about to occur, the brain sends a message to the nervous system, which responds by releasing adrenaline. Increased adrenaline causes us to feel alert and energetic, and gives us a spurt of strength, preparing us to attack (fight) or escape to safety (flight). Increased adrenaline can also have unpleasant side-effects. These can include feeling nervous, tense, dizzy, sweaty, shaky or breathless. Such effects can be disturbing, but they are not harmful to the body and generally do not last long.

How does anxiety affect us?

Whenever the fight or flight response is activated by danger, either real or imagined, it leads to changes in three “systems of functioning”: the way you think (cognitive), the way your body feels and works (physical), and the way you act (behavioural). How much these three systems change varies, depending on the person and the context.

  1. cognitive: Attention shifts immediately and automatically to the potential threat. The effect on a person’s thinking can range from mild worry to extreme terror.

  2. physical: Effects include heart palpitations or increased heart rate, shallow breathing, trembling or shaking, sweating, dizziness or lightheadedness, feeling “weak in the knees,” freezing, muscle tension, shortness of breath and nausea.

  3. behavioural: People engage in certain behaviours and refrain from others as a way to protect themselves from anxiety (e.g., taking self-defence classes or avoiding certain streets after dark).


It is important to recognize that the cognitive, physical and behavioural response systems of anxiety often change together. For instance, if you are spending a lot of time worrying about your finances (cognitive), you are likely to feel physically on edge and nervous (physical), and may spend quite a bit of time checking your household budget and investments (behavioural). Or if you’re preparing for an important exam, you may worry about doing your best (cognitive), feel tense and maybe even have “butterflies” (physical), and initially avoid studying and then cram at the last minute (behavioural).
The key points to remember about anxiety are that it is:
  • normal and experienced by every living organism
  • necessary for survival and adaptation
  • not harmful or dangerous
  • typically short-lived
  • sometimes useful for performance (at low or moderate levels).

When is anxiety a problem?

Everyone experiences symptoms of anxiety, but they are generally occasional and short-lived, and do not cause problems. But when the cognitive, physical and behavioural symptoms of anxiety are persistent and severe, and anxiety causes distress in a person’s life to the point that it negatively affects his or her ability to work or study, socialize and manage daily tasks, it may be beyond normal range.
The following examples of anxiety symptoms may indicate an anxiety disorder:
  1. cognitive: anxious thoughts (e.g., “I’m losing control”), anxious predictions (e.g., “I’m going to fumble my words and humiliate myself”) and anxious beliefs (e.g., “Only weak people get anxious”).
  2. physical: excessive physical reactions relative to the context (e.g., heart racing and feeling short of breath in response to being at the mall). The physical symptoms of anxiety may be mistaken for symptoms of a physical illness, such as a heart attack.
  3. behavioural: avoidance of feared situations (e.g., driving), avoidance of activities that elicit sensations similar to those experienced when anxious (e.g., exercise), subtle avoidances (behaviours that aim to distract the person, e.g., talking more during periods of anxiety) and safety behaviours (habits to minimize anxiety and feel “safer,” e.g., always having a cell phone on hand to call for help).
Several factors determine whether the anxiety warrants the attention of mental health professionals, including:
  • the degree of distress caused by the anxiety symptoms
  • the level of effect the anxiety symptoms have on a person’s ability to work or study, socialize and manage daily tasks
  • the context in which the anxiety occurs.

What are the anxiety disorders?

An anxiety disorder may make people feel anxious most of the time or for brief intense episodes, which may occur for no apparent reason. People with anxiety disorders may have anxious feelings that are so uncomfortable that they avoid daily routines and activities that might cause these feelings. Some people have occasional anxiety attacks so intense that they are terrified or immobilized. People with anxiety disorders are usually aware of the irrational and excessive nature of their fears. When they come for treatment, many say, “I know my fears are unreasonable, but I just can’t seem to stop them.”
The major categories of anxiety disorders are classified according to the focus of the anxiety. A brief description of each is given below, based on the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Although each anxiety disorder can have many different symptoms, one representative example has been chosen to illustrate the typical cognitive, physical and behavioural symptoms of each disorder.

Panic disorder (with or without Agoraphobia)

Description

  • Panic disorder involves “repeated, unexpected panic attacks (e.g., heart palpitations, sweating, trembling) followed by at least one month of persistent concern about having another panic attack” (APA, 2000, pp. 432–433).
  • Panic attacks may be accompanied by agoraphobia, when someone avoids or endures—with marked distress—specific situations, such as being outside the home alone, being in a crowd or standing in a line.

Examples of symptoms

Cognitive
  • “I’m having a heart attack.”
  • “I’m suffocating.”
Physical
  • accelerated heart rate
  • chest pain or discomfort
  • dizziness or nausea
  • trembling or shaking
  • shortness of breath
Behavioural
  • avoidance of places where the person had anxiety symptoms in the past (e.g., a certain grocery store) or similar places (e.g., all grocery stores)
  • avoidance of travel, malls, line-ups
  • avoidance of strenuous activities (e.g., exercise)

Specific phobia

Description

  • A specific phobia involves a “marked and persistent fear of clearly discernible, circumscribed objects or situations” (APA, 2000, p. 405).
  • There are five subtypes of specific phobia: animal type, such as fear of mice or spiders; natural environment type, such as fear of storms or heights; blood-injection-injury type, such as fear of seeing blood or receiving an injection; situational type, such as fear of public transportation, elevators or enclosed spaces; and other type, such as fear of choking or vomiting.

Examples of symptoms

Cognitive
  • “This plane will crash.”
  • “We are all going to die.”
Physical
  • sweating
  • muscle tension
  • dizziness
Behavioural
  • avoidance of air travel
  • need to escape

Social phobia

Description

  • Social phobia involves a “marked and persistent fear of social or performance situations in which embarrassment may occur” (APA, 2000, p. 450).
  • Fears might be associated with most social situations related to public performance or social interactions, such as participating in small groups, meeting strangers, dating or playing sports.

Examples of symptoms

Cognitive
  • “I’ll look anxious and stupid.”
  • “People will think I’m weird.”
Physical
  • blushing
  • sweating
  • dry mouth
Behavioural
  • avoidance of social gatherings, parties, meetings
  • avoidance of public speaking

Obsessive-compulsive disorder

Description

  • Obsessive-compulsive disorder (OCD) involves “recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment” (APA, 2000, p. 417).
  • Obsessions are uninvited or “intrusive” thoughts, urges or images that surface in the mind over and over again, such as concerns about contamination (e.g., from touching door handles) or doubting (e.g., “Did I lock the door?”).
  • Compulsions are behaviours or “rituals” that the person follows to try to reduce or suppress his or her obsessive thoughts (e.g., hand washing, checking).

Examples of symptoms

Cognitive
  • “I’m going to get sick and infect the entire family if I touch this door handle.”
Physical
  • muscle tension
  • discomfort
Behavioural
  • excessive washing, cleaning and/or checking
  • avoidance of doors and public washrooms

Acute Stress Disorder

Description

  • Acute stress disorder can occur after someone has “experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (APA, 2000, p. 431).
  • The disorder occurs within one month of a traumatic event.
  • Disturbing memories of the traumatic event cause an emotional reaction and a sense of reliving the event.

Examples of symptoms

Cognitive
  • “I’m going to be trapped and die in a car crash.”
  • “I’ve escaped being killed once—I won’t be so lucky a second time!”
  • “The world is not safe.”
Physical
  • restlessness, difficulty sleeping and concentrating
  • exaggerated startle response
  • feeling tense and on edge and/or numb
Behavioural
  • avoidance of situations that arouse recollections of trauma
  • intense emotional reaction or absence of emotional responsiveness

Post-traumatic stress disorder

Description

  • Posttraumatic stress disorder (PTSD) involves the “development of characteristic symptoms following exposure to an extreme traumatic stressor” (APA, 2000, p. 463).
  • “The person’s response to the event must involve intense fear, helplessness, or horror” (APA, 2000, p. 463).
  • “Symptoms usually begin within three months of the trauma, although there may be a delay of months, or even years before the symptoms appear” (APA, 2000, p. 466).
  • The traumatic experience is repeatedly relived through intrusive memories, distressing dreams and flashbacks.

Examples of symptoms

Cognitive
  • “I now realize that I’m never safe.”
  • “People aren’t to be trusted.”
Physical
  • sleep disturbance, nightmares
  • irritability or outbursts of anger
  • hypervigilance for danger
Behavioural
  • avoidance of thoughts, feelings, conversations, activities, places or people associated with the trauma (e.g., emergency vehicles, parking lots)

Generalized Anxiety Disorder

Description

  • Generalized anxiety disorder (GAD) involves “excessive anxiety and worry, occurring more days than not for a period of at least six months, about a number of events or activities” (APA, 2000, p. 472).
  • GAD is characterized by “difficulty in controlling worry” (APA, 2000, p. 472).

Examples of symptoms

Cognitive
  • “Something’s going to go wrong.”
  • “This worry is going to make me nuts.”
Physical
  • muscle tension
  • inability to relax
  • restlessness, irritability
  • sleep disturbed by worry
Behavioural
  • avoidance of news, newspapers
  • restricted activities due to excessive worries about what could happen
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