Anxiety and the Treatment of Anxiety Disorders*

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Everybody knows what it's like to feel anxious - it's the butterflies in the stomach when faced with a difficult challenge or frightening set of circumstances. Anxiety rouses us to action; it gears us up to face a threatening situation. It makes us study harder for an exam, and keeps us on your toes when we're making a speech. In general, it's the body's "call to action" that helps us cope and rise to life's challenges.

Decades of psychological research have demonstrated that the relationship between emotional arousal and human performance follows an inverted "U-shaped" curve; that is, behavioral performance improves with increased arousal, up to an optimal level, beyond which performance is increasingly impaired by arousal. As arousal increases beyond the optimal level, we feel increasingly anxious, and at some point this begins to degrade our ability to cope and perform. When this heightened level of anxiety becomes enduring, when we get "stuck" and it begins to negatively affect our day-to-day functioning and sense of well-being, we describe the arousal as having transitioned into an "anxiety disorder." There are several types of anxiety disorders (including generalized anxiety disorder (GAD), agoraphobia and panic disorder, specific and non-specific phobias, obsessive compulsive disorder, and post-traumatic stress disorder PTSD), and some disorders appear to result biologically from a genetic predisposition.

Generalized Anxiety Disorder (GAD)

• GAD is a chronic state of exaggerated worry and tension and usually includes a constant anticipation of disaster. People with this disorder are unable to relax and often have difficulty falling or staying asleep. Their constant state of distress is often accompanied by multiple physical sensations, including muscle tension and trembling, nausea, headaches, irritability, lightheadedness, shortness of breath, and tightness in the chest.
• GAD and other anxiety disorders also can be accompanied by clinical depression, with symptoms of sadness, apathy, hopelessness, changes in appetite and/or sleep, and difficulty concentrating and thinking clearly.
• Generalized Anxiety Disorder has a gradual onset, usually beginning in childhood or adolescence, although it can commence in adulthood. It is more common in women than in men and often occurs in relatives of affected persons. The symptoms frequently diminish with age.
• Treatment may include medication, particularly if there is accompanying depression. Because of the nature of anxiety disorders, there can be a risk of developing psychological dependency on medications, particularly on the faster acting benzodiazepines (Xanax, Ativan, Klonopin, Valium). For this reason, the staff of the Maryland Institute usually recommend a trial of anti-depressant medication (such as paroxetine or Paxil) or a brief (one month or less) trial of benzodiazepine.

Panic Disorder

• People with panic disorder have feelings of terror that strike suddenly and repeatedly, usually without warning. They can't predict when an attack will occur and often develop intense anxiety between episodes worrying when the next attack will strike. The symptoms include pounding heart, chest pains, profuse sweating and dizziness, nausea, shaking and trembling, and feelings of terror, unreality, being out of control, or going crazy. Attacks usually last only a few minutes and can occur at any time, including during non-dream sleep.
• Panic disorder is twice as common in women as in men and can occur at any age, most frequently occurring in young adulthood.
• Panic disorder may be accompanied by depression or alcoholism, and may spawn phobias that occur in places or situations where panic attacks have occurred. This may lead to significant restrictions in a person's life, and eventually to agoraphobia ("fear of the market place") where a person may be fearful of venturing outside the home.
• Research shows that proper treatment with cognitive-behavioral psychotherapy, temporarily supported by medication (anti-depressant or benzodiazepine) if necessary, can successfully treat 70-80 percent of people with panic disorder. Significant improvement is usually seen within 6 to 8 weeks.

Phobias

• Phobias occur in several forms, including specific phobia (fear of a specific object or situation), social phobia (fear of painful embarrassment in a social setting), and agoraphobia (fear of being in situations that might provoke a panic attack, or from which escape might be difficult if an attack occurred).
• Phobias contain the elements of extreme fear and irrationality; for example, a person may be able to ski the world's tallest mountains, but feel panic going above the tenth floor of an office building or crossing the Chesapeake Bay Bridge.
• Phobias affect approximately one in ten people and spontaneously remit (disappear on their own) only 20 percent of the time.
• Cognitive-behavioral psychotherapy is effective approximately 75 percent of the time; no known drug treatments have been shown effective, although medication may be used selectively as a treatment adjunct.

Social Phobia

• Social phobias an intense fear of embarrassment and humiliation in social situations. The most common social phobia is a fear of public speaking, and often it involves a more general fear of social situations such as parties. More rarely it may involve a fear of using a public restroom, dining out, talking on the phone, or writing in the presence of others (writing a check in front of a store clerk).
• Social phobia often runs in families and may be accompanied by depression or alcoholism; the symptoms often begin in childhood or early adolescence. It is distinct from shyness, in that socially shy people do not experience intense fear or dread of social situations, and those with social phobia are not necessarily shy or reserved in other situations.
• Approximately 80 percent of people with social phobia are successfully treated with cognitive-behavioral psychotherapy, either alone or in combination with medication. The medications that have been found effective include different types of anti-depressants, including serotonin re-uptake inhibitors (SRIs) such as Paxil and Prozac, and MAO (monoamine oxidase) inhibitors (Nardil and Parnate). The latter are rarely used in the USA, however, because of the drugs' interaction effects with foods (cheese) and other medications.

Obsessive-Compulsive Disorder (OCD)

• Obsessive-compulsive disorder is characterized by anxious thoughts or rituals of behavior that a person feels they can't control. People with OCD may be obsessed with germs and dirt and feel the need for constant hand-washing, or be filled with doubt and feel the need to check things repeatedly. They may spend long periods of time touching things or counting, or be preoccupied with a need for order and symmetry. The disturbing thoughts and impulses that characterize the disorder are called obsessions, and the rituals that are performed to ward off or prevent the anxiety are called compulsions.
• OCD strikes men and women in equal numbers and afflicts approximately one in fifty people. Specialists in the field of addictions often speak of "compulsive" substance use/abuse, and it seems that persons with OCD may be especially prone to problems of addiction and eating disorders. A third of adults with OCD experienced their first symptoms as children, and OCD may accompany neurodevelopmental disorders such as attention deficit disorder (ADHD), Tourette's (facial, vocal and motor tics), Asperger's, and other pervasive developmental disorders.
• OCD can be effectively treated with behavior therapy (see Dealing with Obsessions and Compulsions on this WEB site) and medications, including fluvoxamine (Luvox), fluoxetine (Prozac), and clomipramine (Anafranil).

Post-Traumatic Stress Disorder (PTSD)

• PTSD is a debilitating anxiety condition that follows a terrifying, overwhelming, and uncontrollable event. People with PTSD often experience persistent thoughts and memories of their ordeal ("flashbacks") , and may also experience some degree of emotional "numbing" or dissociation. PTSD was first diagnosed in combat veterans (described as "shell shock" and "battle fatigue"), and later was recognized as a response to other catastrophic events, such as major car or train accidents, natural disasters (earthquakes, floods), and violent assaults and attacks (rape, torture, kidnapping). Less severe forms of PTSD also occurs as "secondary trauma" in individuals who observe or deal with the victims of trauma and disasters.
• Some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They also may experience sleep problems, depression, feeling detached or numb, or being hypervigilant or easily startled. They may feel irritable and more easily angered and aggressive than before. They may find themselves avoiding people, places, or circumstances that remind them of the trauma.
• PTSD can occur at any age, including childhood, and the symptoms may be mild and short-lived, or severe and chronic. PTSD is diagnosed only if the symptoms last more than one month. In those diagnosed, the symptoms usually begin within 3 months of the trauma, although evidence of the disorder may be delayed for months or years, until events or circumstances elicit the symptoms.
• PTSD can be successfully treated with psychotherapy, frequently supported with anti-depressant medication (SRI's such as Prozac, Paxil and Zoloft) when the symptoms are particularly intense. A newer behavioral treatment, "Eye Movement Desensitization and Reprocessing" (EMDR), has been widely cited as effective and used in numerous disaster situations such as the bombing of the Oklahoma City federal building. Successful treatment can occur rapidly, but generally takes longer with more sever symptoms, or when there are other, co-morbid (accompanying) diagnoses, such as substance abuse/dependency or personality disorders that can occur as a developmental response to chronic traumatization.

* Adapted from NIH Publication No. 95-3879. For further information, contact the National Institute of Mental Health (NIMH), 5600 Fishers Lane, Room 7C-02, Rockville, MD 20857-8030.

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