Nevertheless, when anxiety becomes extreme or when an attack of anxiety strikes suddenly, without an apparent external cause, it can be both debilitating and destructive. Its symptoms may include nervousness, fear, a "knot" in the stomach, rapid heartbeat, or increased blood pressure. If the anxiety is severe and long lasting, more serious problems may develop. People suffering from anxiety over an extended period may have headaches, ulcers, irritable bowel syndrome, insomnia, and depression. Because anxiety tends to create various other emotional and physical symptoms, a "snowball" effect can occur in which these problems produce even more anxiety.
Chronic anxiety can interfere with an individual's ability to lead a normal life. Mental health professionals consider a person who has prolonged anxiety as having an anxiety disorder. The NIMH estimates that approximately nineteen million Americans suffer from anxiety disorders.
TABLE 8.5 Prevalence of anxiety disorders
| TABLE 8.5 | ||
|---|---|---|
| Prevalence of anxiety disorders | ||
| Percent | Population estimate* (millions) | |
| *Based on 7/1/98 U.S. Census resident population estimate of 143.3 million, age 18-54. | ||
| SOURCE: "Anxiety Disorders One-Year Prevalence (Adults)," in Facts about Anxiety Disorders, National Institute of Mental Health, 2005, http://www.nimh.nih.gov/publicat/NIMHadfacts.pdf (accessed January 19, 2006) | ||
| Any anxiety disorder | 13.3 | 19.1 |
| Panic disorder | 1.7 | 2.4 |
| Obsessive-compulsive disorder | 2.3 | 3.3 |
| Post-traumatic stress disorder | 3.6 | 5.2 |
| Any phobia | 8.0 | 11.5 |
| Generalized anxiety disorder | 2.8 | 4.0 |
Panic Disorder
Extremely high levels of anxiety may produce panic attacks that are both unanticipated and seemingly without cause. In one type of panic attack, termed "unexpected," the sufferer is unable to predict when an attack will occur. Other types of panic attacks are linked to a particular location, circumstance, or event and are called "situationally bound" or "situationally predisposed" panic attacks. These panic episodes can last as long as thirty minutes and are marked by an overwhelming sense of impending doom while the person's heart races and breathing quickens to the point of gasping for air. Sweating, weakness, dizziness, terror, and feelings of unreality are also typical. Individuals undergoing a panic attack fear they are going to die; "lose their mind"; or, at the very least, lose control.
Repeated panic attacks may be termed a panic disorder. However, panic attacks do not necessarily indicate a mental disorder—up to 10% of people with no other problems experience a single panic attack each year. According to the APA, panic disorder occurs twice as often among women than men, it can run in families, and most sufferers begin to experience attacks in their twenties. Research has revealed that persons who experience panic attacks tend to suppress their emotions. Investigators hypothesize that this tendency leads to an emotional buildup for which a panic attack is a form of release. Interestingly, most persons who suffer from panic attacks do not experience anxiety between attacks.
These symptoms often mimic those of a heart attack, so the diagnosis of panic disorder often is not made until extensive and costly medical procedures fail to provide a diagnosis. These patients then may turn to neurologists and other specialists to seek answers. Research has found that of the patients who make the most visits to doctors, spend the most time in the hospital, and use the most prescription medications, approximately 12% suffer from undiagnosed panic disorders.
The usual treatment for panic disorder is cognitive behavioral therapy combined with antianxiety drugs to treat the fear of the attacks. Sometimes antidepressant medications are used, although persons suffering from anxiety disorders are usually not clinically depressed. Relaxation therapy also has proved beneficial.
Phobias
Phobias are defined as unreasonable fears associated with a particular situation or object. The most common of the many varieties of phobias are specific phobias. Fear of bees, snakes, rodents, heights, odors, blood, injections, and storms are examples of common specific phobias. Specific phobias, especially animal phobias, are common in children, but they can occur at any age. About 8% of American adults (11.5 million) suffer from specific phobias. (See Table 8.5.) Most people with a phobia understand that their fears are unreasonable, but that awareness does not make them feel any less anxious.
Some specific phobias, such as a fear of heights, usually do not interfere with daily life or cause as much distress as more severe forms, such as agoraphobia (see later in this chapter). People suffering from severe phobias may rearrange their lives drastically to avoid the situations they fear will trigger panic attacks.
SOCIAL PHOBIAS
Social phobias (also called social anxiety disorders) can be more serious than specific phobias. The person with a social phobia is intensely afraid of being judged by others. At social gatherings the person with social phobia expects to be singled out, scrutinized, judged, and found lacking. People with social phobias are usually very anxious about feeling humiliated or embarrassed. They are often so crippled by their own fears that they may have a hard time thinking clearly, remembering facts, or carrying on normal conversations. The individual with social phobia may tremble, sweat, or blush and often fears fainting or losing bladder or bowel control in social settings. In response to these overwhelming fears, the person with social phobia tries to avoid public situations and gatherings of people. Social phobias tend to start between the ages of fifteen and twenty years and, if not treated, can continue throughout life.
Because social phobics fear being the center of attention or the subject of criticism, public speaking, asking questions, eating in front of others, or even attending social events create anxiety. Social phobias should not be confused with shyness, which is considered a normal variation in personality. Social phobias can be disabling, preventing sufferers from attending school, working, and having friends.
AGORAPHOBIA
Many people who experience panic attacks go on to develop agoraphobia—the fear of crowds and open spaces. The term comes from the Greek word "agora," which means "marketplace." This type of phobia is a severely disabling disorder that often traps its victims, rendering them virtual prisoners in their own homes, unable to work, shop, or attend social activities.
Agoraphobia normally develops slowly, following an initial unexpected panic attack. For example, on an ordinary day, while shopping, driving to work, or doing errands, the individual is suddenly struck by a wave of terror characterized by symptoms such as trembling, a pounding heart, profuse sweating, and difficulty in breathing normally. The person desperately seeks safety, reassurance from friends and family, or a physician. The panic subsides and all is well—until another panic attack occurs.
The person with agoraphobia begins to avoid all places and situations where an attack occurred and then begins to avoid places where an attack could possibly occur or where it might be difficult to escape and get help. Gradually, the victim becomes more and more limited in the choice of places that are "safe." Eventually, the person with agoraphobia cannot venture outside the immediate neighborhood or leave the house. The fear ultimately expands to touch every aspect of life.
Agoraphobia usually begins during the late teens or twenties. The Surgeon General states about 5% of the adult population suffers from it, and women tend to be affected two times more often than men.
PHOBIA TREATMENT PROGRAMS
Phobia treatment centers exist throughout the United States. The programs use a wide variety of cognitive behavioral therapy techniques to help patients face and overcome their fears. In addition, drugs may be used to ease the symptoms of anxiety, fear, and depression and to help the person return to a normal life more quickly. Antidepressants have been shown to help people who suffer from panic attacks and agoraphobia. In addition, anti-anxiety drugs are useful in treating the generalized anxiety that frequently accompanies phobias.
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is an anxiety disorder marked by unwanted, often unpleasant recurring thoughts (obsessions) and repetitive, often mechanical behaviors (compulsions). The repetitive behaviors, such as continually checking to be certain windows and doors are locked or repeated hand washing, are intended to dispel the obsessive thoughts that trigger them—that an intruder will enter the house through an unlocked door or window, or that disease will be prevented by hand washing. The vicious cycle of obsessions and compulsions only serves to heighten anxiety; OCD can debilitate those who have the disorder.
The NIMH estimates that about 2.3% of adults between the ages of eighteen and fifty-four suffer from OCD annually. (See Table 8.5.) OCD strikes men and women equally; it sometimes coexists with other disorders such as substance abuse, eating disorders, or depression; and its symptoms generally appear during childhood or adolescence. Imaging studies using positron emission tomography (PET) reveal that people with OCD have different patterns of brain activity than those without the disorder. Further, the PET scans show that the part of the brain most affected by OCD (the striatum) changes and responds to both medication and behavioral therapy.
Many of the medications used to treat other anxiety disorders appear effective for patients with OCD along with a behavioral type of therapy called "exposure and response prevention," during which patients with OCD learn new ways to manage their obsessive thoughts without resorting to compulsive behaviors.
Anxiety among Children and Adolescents
Children and adolescents suffer from many of the same anxiety disorders as do adults. Taken together, the different types of anxiety disorders constitute the mental disorders most prevalent among children and adolescents. According to the Surgeon General's report, 13% of children ages nine to seventeen suffer from some form of anxiety disorder. (See Table 8.1.)
Separation anxiety disorder is a type of anxiety disorder found specifically in children. It is normal for infants, toddlers, and very young children to experience anxiety when separated from their parents or caregivers. For example, nearly every child experiences at least a momentary pang of separation anxiety on the first day of preschool or kindergarten. When this condition occurs in older children or adolescents and it is severe enough to impair social, academic, or job functioning for at least one month, it is considered separation anxiety disorder. The risk factors associated with separation anxiety disorder include stress, such as the illness or death of a family member, geographic relocation, and physical or sexual assault.
Children with separation anxiety may be clingy, and often they harbor fears that accidents or natural disasters will forever separate them from their parents. Because they fear being apart from their parents, they may resist attending school or going anywhere without a parent. Separation anxiety can produce physical symptoms such as dizziness, nausea, or palpitations. It is often associated with symptoms of depression. Young children with separation anxiety may have difficulties falling asleep alone in their rooms and may have recurrent nightmares.
Obsessive-compulsive disorder (OCD) often begins during childhood or adolescence. There is evidence from twin studies of both genetic susceptibility and environmental influences. When one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twins. There is also increased incidence of the disorder among first-degree relatives of children with OCD. Researchers do not think that OCD is a learned behavior—that the affected child is mimicking the family member's behavior—because children with OCD tend to display different symptoms from those of relatives with the disease.
According to the Surgeon General's report, research suggests that some children develop OCD following an infection with a specific type of streptococcus. This condition is known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). It is believed that antibodies intended to combat the strep infection mistakenly attack a region of the brain and trigger an inflammatory reaction, which in turn leads to development of OCD. SSRIs are effective in reducing or even eliminating the symptoms of OCD in many affected children and adolescents. However, side effects such as dry mouth, sleepiness, dizziness, fatigue, tremors, and constipation are common and may themselves impair functioning.
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