Anxiety Disorders

Anxiety is the anticipation of danger, a negative event or a negative outcome. Nearly all people experience anxiety at times. An anxiety disorder is an excessive level of anxiety that typically persists for at least six months and causes a great deal of unhappiness or creates problems in a person’s life. A person who suffers from an anxiety disorder may avoid situations or endure feared situations with a great deal of distress.

According to the National Institute of Mental Health, an estimated 40 million Americans, or 18 percent of adult men and women, experience this illness within a given year. As many as 33 percent of American men and women may experience an anxiety disorder at some point in their lifetime.

Anxiety can be expressed physically through symptoms such as:

A rise in blood pressure
A fast heart rate
Rapid breathing
An increase in muscle tension
Nausea or diarrhea
Anxious behaviors can include:

Avoidance
Seeking reassurance
Ritualistic behaviors such as checking, repeating, making things “just right”
Overpreparing
Restlessness or fidgeting
Anxious thoughts typically focus on potential negative outcomes or scenarios or negative past events such as trauma, feared mistakes or embarrassing situations.

Without treatment, an anxiety disorder can significantly disrupt a person’s life because symptoms may persist or become progressively worse. Tormented by panic attacks, irrational thoughts and fears, compulsive behaviors or rituals, flashbacks, nightmares or countless frightening physical symptoms, people with anxiety disorders may seek help in emergency departments and often rely heavily on other medical services to address their symptoms.

Their work, family and social lives are disrupted, and some even become housebound. Individuals with anxiety disorders may have other mental disorders such as depression or substance abuse.

Fortunately, treatment for anxiety disorders is, in general, very effective. Early diagnosis may aid early recovery, prevent the disorder from becoming worse and possibly prevent the disorder from developing into depression. Yet, because of a widespread lack of understanding and the stigma associated with anxiety disorders, only about one-third of those who experience them are diagnosed and receive treatment.

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association defines several anxiety disorders. Additionally, they identify obsessive compulsive disorder and post-traumatic stress disorder as closely related to the anxiety disorders. For simplicity, this article uses the term anxiety disorders collectively to include the following:

Generalized anxiety disorder (GAD) affects about 6.8 million Americans and affects nearly twice as many women as men. GAD is characterized by at least six months of a more-or-less constant state of tension or worry. A person with GAD may always expect a catastrophe to happen. The person may worry even when things are going relatively well. The anxious thoughts and feelings are difficult to control or turn off. The worries that accompany GAD are focused on one or more areas of a person’s life, such as health, finances, work or relationships. More than half the people who suffer from GAD also have another anxiety disorder or depression.
Panic attacks develop abruptly and generally reach a peak within 10 minutes. They may be triggered by a specific event or situation or may seem to come out of the blue. Common symptoms of panic attacks include heart palpitations; sweating; shaking; a feeling of breathlessness or smothering sensations; numbness or tingling sensations in the hands, face or feet; dizziness or feeling faint, chills or hot flushes; depersonalization or a feeling of an altered reality; fear of dying; fear of having a heart attack; or fear of losing control.
Panic disorder, defined as repeated unexpected panic attacks or worry about such attacks, affects about 6 million Americans. It typically strikes in late adolescence or early adulthood. Women are twice as likely as men to develop panic disorder. People with panic disorder may also suffer from depression, abuse alcohol or abuse drugs such as marijuana. About one-third of people with panic disorder develop agoraphobia, in which a person fears or avoids situations where they believe they will have difficulty escaping or getting help in the event of a panic attack or other embarrassing or unpleasant physical symptoms. People with agoraphobia might avoid driving on the highway, using public transportation, going to crowded places such as shopping malls or concerts and, in severe cases, may avoid leaving their homes.
Phobias are irrational, involuntary fears of common objects, living things or situations, such as heights, small enclosed spaces, animals, insects, air travel, blood or medical procedures. While they vary in severity, phobias can be incapacitating. Most people who suffer from phobias are aware of the irrationality of their fear, yet they avoid the feared objects or situations or endure them with intense anxiety. Specific phobias are among the most common mental health disorders. About 19.2 million Americans suffer from specific phobias, and they are twice as common in women as men.
Social phobia, or social anxiety disorder, is caused by a fear of being embarrassed in a social situation or publicly scrutinized and humiliated. Social phobia is often accompanied by depression and may lead to alcohol or other drug abuse. About 15 million people have social phobia, which is equally common among women and men. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.
Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent and intrusive thoughts, images or impulses that cause anxiety. These mental images or ideas are called obsessions. The person tries to control or neutralize these obsessions and relieve the anxiety by performing repetitive behaviors called compulsions. The compulsions are often rigid and must be performed in a certain time-consuming order. Although adults with OCD often know these rituals are excessive, they cannot stop doing them in spite of strenuous efforts to ignore or suppress the thoughts or actions. Repeated hand washing, reordering of belongings, rechecking objects in one’s house, or silently repeating words, numbers or prayers are examples of compulsions. About 2.2 million Americans have OCD. One-third of adults affected with OCD had their first symptoms in childhood. OCD affects men and women with equal frequency. OCD should not be confused with obsessive-compulsive personality disorder, which is characterized by traits such as being a perfectionist, excessively conscientious, morally rigid and preoccupied with rules and order. These traits do not necessarily occur in people with OCD.
Post-traumatic stress disorder (PTSD) develops after exposure to an extremely stressful event that involved threatened or actual death, serious injury or sexual violence for oneself or someone else. About 7.7 million people suffer from PTSD. It may stem from trauma such as a rape, childhood sexual abuse, military combat or war-related incidents and natural disasters.
Although anxiety is a normal human response to stress, health care professionals and researchers don’t know exactly why some people develop severe anxiety or panic. They believe it is most likely the result of a combination of biological and psychosocial factors such as:

A biological tendency toward anxiety, including greater sensitivity to the effects of hormones released during anxiety, such as adrenaline; or an imbalance of certain substances called neurotransmitters (chemical messengers in the brain)
Genetic or familial factors. People who have close relatives with anxiety disorders are more likely to suffer from anxiety disorders themselves.
Family background, such as an early childhood conflict or trauma, or “learned” fears or phobias
Negative or stressful life events
Other illnesses or medications can cause symptoms of an anxiety disorder
While anxiety disorders can strike anyone of any age, gender or socioeconomic background, they most often begin in young adulthood. They often start mildly and progress, although GAD appears to be the most common form of anxiety in older ages. In addition, except for OCD and social anxiety disorder, anxiety disorders strike women at approximately twice the rate of men.

Diagnosis

The first step to properly diagnosing an anxiety disorder is to rule out another medical condition. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for your health care professional to uncover any physiological medical problems or medications that might underlie or be masked by anxiety symptoms.

Thus, a physical examination and medical and personal history are essential. You should describe any history of anxiety disorders or depression in your family and mention any other contributing factors, such as excessive caffeine use, recent life changes or stressful events. It is very important to be honest with your health care professional about all conditions, including substance abuse or other psychological or mood states that might contribute to or result from the anxiety disorder.

Panic attacks may mimic or accompany diseases of the heart and lungs, but anxiety attacks do not cause heart or lung disease. Anxiety-like symptoms may occur with other medical problems, including epilepsy, hypoglycemia, adrenal-gland tumors and hyperthyroidism. Women can also experience intense anxiety attacks with hot flashes during menopause. Many drugs, including some for high blood pressure, diabetes and thyroid disorders, can produce symptoms of anxiety, as can withdrawing from certain drugs like those used to treat sleep disorders or anxiety.

Panic disorder often coexists with depression, and sometimes the symptoms overlap because anxious feelings, agitation, insomnia and problems with concentration often accompany depression.

Thus, your health care professional will use a medical evaluation to rule out alternative explanations of anxiety symptoms.

Health care professionals can use various tests from the American Psychiatric Association and other professional organizations to determine the causes, type, severity and frequency of your anxiety. Most are written, multiple-choice tests that can be administered on paper or verbally and are centered on defining the kinds of symptoms you experience as part of your anxiety.

Specific anxiety disorders are diagnosed based on the severity and duration of symptoms and on additional behavioral characteristics that accompany the symptoms of anxiety. Specifically:

Generalized anxiety disorder (GAD) is confirmed if you meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. These criteria include:
Excessive anxiety and worry about several events and activities more days than not for at least six months
The anxiety is not better explained by other mental health issues, such as post-traumatic stress disorder (PTSD), substance abuse or panic disorder
Difficulty controlling feelings of worry
At least three of the following symptoms in adults and one in children: fatigue, restlessness, trouble concentrating, muscle tension, sleep problems or irritability
Symptoms should cause significant distress and impair normal functioning.

Panic disorder is diagnosed if you meet the diagnostic criteria outlined in the DSM, including:
Recurrent, unexpected panic attacks
Worry about having another panic attack or losing control
Avoidance of situations you think may trigger a panic attack
Panic attacks that aren’t caused by substance abuse or another mental health condition such as social phobia or agoraphobia
Panic attacks include four or more of the following symptoms that develop suddenly and reach a peak within 10 minutes:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Chills or heat sensations
Numbness or tingling sensations
Feelings of unreality or depersonalization
Fear of losing control or going crazy
Fear of dying
Agoraphobia occurs in about one-third of people with panic disorder. It involves fear or avoidance of multiple situations such as using public transportation, being in open spaces such as marketplaces or bridges, being in closed spaces such as theaters or shops, standing in line or being in a crowd, or being outside of the home alone. In such situations, the person typically worries that there would be no escape or help would be unavailable should panic-like symptoms or other unpleasant or embarrassing symptoms occur. A person with agoraphobia might make complicated plans to avoid confronting feared situations and limit herself to places that feel safe such as home.
Specific phobias occurs when someone fears and may avoid specific objects, living things or situations such as small enclosed spaces, particular animals or insects, heights, air travel, blood, injury or injections. Although people with specific phobias may have panic attacks, their fear is not focused on panic symptoms. Instead, they worry that the feared object or situation itself will cause harm (e.g., the plane will crash, they will fall or jump from a high place, a dog will bite them). A person with a specific phobia may experience the following symptoms around the phobic object or situation:
Panicky feelings
Sweating
Rapid heartbeat
Avoidance behavior
Difficulty breathing
Social phobia, also known as social anxiety disorder, is a fear of being embarrassed or negatively evaluated in social situations. Symptoms vary in intensity, ranging from mild and tolerable anxiety to a full-blown panic attack. People with social phobia worry that others will perceive them as boring, stupid, weird or unlikable. They may also worry that their anxiety will be evident due to blushing, trembling, shaking or stammering. Social phobia is often accompanied by depression and may lead to substance abuse.
Obsessive-compulsive disorder (OCD) is diagnosed if obsessions and compulsions interfere with your normal activities or cause emotional distress or anxiety, especially if the ritualistic behavior cannot be carried out. Adults with this condition usually recognize their obsessions or compulsions as excessive and unreasonable, yet feel compelled to engage in them. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre or frightening fantasies of behaving violently toward a loved one. The compulsive acts triggered by such obsessions might include repetitive checking of locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or spend inordinate amounts of time cleaning their surroundings to subdue the fear of contagion.Certain other obsessive disorders, including body dysmorphic disorder (BDD), trichotillomania and Tourette’s disorder, may be part of the OCD spectrum. In BDD, people are obsessively preoccupied with an imagined defect in their appearance. People with trichotillomania continually pull out their hair, sometimes leaving bald patches. Symptoms of Tourette’s disorder include both motor tics, like eye blinking, facial twitching and jerking motion of arms or head, and vocal tics, like grunting, sniffing and throat clearing. These symptoms usually start before age 18 and continue for at least one year.
Post-traumatic stress disorder (PTSD) symptoms can occur weeks, months or even years after the traumatic event. A person who suffers from PTSD may have the following symptoms:
Recurrent intrusive memories or distressing dreams about the event
Dissociative reactions in which the person feels the event is recurring
Avoidance of reminders of the event
Sleeplessness
Depression
Irritability or angry outbursts
Feelings of being “on alert” at all times
Emotional withdrawal
Hopelessness
Mood swings
Guilt over surviving the event
Inability to concentrate
Excessive startle response to noise
Acute stress disorder (ASD) is similar to PTSD, except it can be diagnosed immediately after a traumatic event and lasts for three days or more, but no longer than one month after the trauma. Like PTSD, it is triggered by a traumatic event such as witnessing a car accident or natural disaster or being violently assaulted. ASD symptoms overlap with those of PTSD. In some cases, anger or dissociative symptoms, such as not knowing where you are or feeling separate from your body, may be the main symptoms. Some people who suffer ASD may have previously had PTSD, and many who get ASD go on to develop PTSD.
Finding the Right Health Care Professional

Because of widespread lack of understanding and the stigma associated with anxiety disorders, many people with these disorders don’t receive a diagnosis and so don’t receive treatments proven effective through research. Yet anxiety disorders, like other mental disorders, are an illness and should not be faced with shame or fear. Enormous progress has been made in the scientific understanding of the underlying causes and mechanisms of anxiety disorders.

To be a smart health care consumer, you need to ensure that the health care professional you see is able to recognize an anxiety disorder. While mental health treatment can be received from a wide range of professionals, including primary care physicians, psychiatrists, psychologists and social workers, you may want to consider seeking out an anxiety specialist, particularly someone who can offer the treatments found to be most successful, such as cognitive behavioral therapy and medications.

You can contact the Anxiety Disorders Association of America or the Association for Behavioral and Cognitive Therapies to find professionals specializing in anxiety. Make sure you follow the steps for seeking treatment as outlined in your health insurance plan. You may be required, for example, to see a primary care physician first. Some health insurance plans cover mental health services; some don’t. Check your policy or ask your plan administrator so you can determine what your out-of-pocket expenses might be. Don’t overlook the simple fact that you should like your treating professional. If you can’t develop a rapport within the first two or three sessions, your therapy probably won’t be successful, so keep searching for someone with whom you’re comfortable.

Treatment

Anxiety disorders require professional treatment; simply trying to talk yourself out of anxiety is as futile as trying to talk yourself out of a heart or stomach problem. Fortunately, the vast majority of people with an anxiety disorder can be helped with the right professional care. Research suggests that with the right treatment, many people with anxiety disorders experience significant improvement. There are no guarantees, however, and success rates vary with circumstances.

Treatment periods vary, with some requiring only a few months of treatment and others needing a year or more. People with anxiety disorders often have more than one disorder or suffer from substance abuse or clinical depression. When more than one mental health-related condition is present, each must be accurately diagnosed and treated.

Treatments for anxiety disorders vary, with both therapy, particularly cognitive behavioral therapy (CBT), and medication, used. Often, the most effective approach for anxiety disorders is a combination of the two. With OCD, a specific type of CBT called exposure and response prevention should be used, usually in combination with medication.

Medications

Medications used to treat anxiety disorders include:

Selective serotonin reuptake inhibitors (SSRIs) are first-line medicines used to treat anxiety disorders. Although these medications were initially approved as antidepressants, they are effective in the treatment of anxiety. Some of them have been approved by the FDA for the treatment of one or more of the anxiety syndromes. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), fluvoxamine (Luvox) and escitalopram oxalate (Lexapro). They work by affecting the concentration of serotonin, a chemical in the brain thought to be linked to anxiety disorders, and have traditionally been used to treat depression. SSRIs may take several weeks to have an effect. They should not be stopped suddenly as they may cause withdrawal symptoms that are unpleasant but not harmful.The most common side effects are nausea and gastrointestinal problems, drowsiness, sweating, headache, difficulty sleeping and mild tremor, all of which usually wear off as your body adjusts to the medication. Weight gain and sexual dysfunction can also be side effects of this category of medications. Occasionally they can cause agitation or worsening of anxiety. Notify your clinician immediately if this occurs.
Tricyclic antidepressants (TCA) are older medications that were first used for treating depression. They are also effective in blocking panic attacks and for anxiety and PTSD because they regulate serotonin and/or norepinephrine in the brain. The most common TCAs used for the treatment of panic disorder are imipramine (Tofranil), desipramine (Norpramin) and nortriptyline (Pamelor). TCAs are also effective in treating agoraphobia.Clomipramine (Anafranil), which is the only TCA approved for obsessive-compulsive disorder (OCD), significantly reduces symptoms for patients who can tolerate it.

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