Anxiety disorders: recognizing the symptoms of six of the most common anxiety disorders.

It has often been said that we live in an age of anxiety, this despite the fact that the standard of living of the population of the developed world is at a level never before attained. Given the fact that famine and pestilence have been largely overcome in the industrialized world, it is strange that anxiety is so prevalent. That is not to say that developed societies are free of illnesses, but epidemics of the past wiped out large portions of the population where today this is now rare. However, even with these apparent accomplishments, some 20 million American adults live with an anxiety disorder that is chronic, painful and which can become progressively worse. We can speculate that evolution has prepared us for starvation and pestilence, but it has not prepared us for the stresses of contemporary modern life.

The stresses we face today are the results of a complex environment and culture. Stresses such as overcrowding, competitiveness and the loss of communal supports may well contribute to why so many people suffer from anxiety. This can be a particular problem for individuals who have a disability. In addition to the limitations the disability may place upon the individual, there is also the problem that stigma and social rejection may be associated with that disability. For example, being the object of ridicule by classmates as a child grows up can be devastating to that child's self-esteem. Obviously, families caring for individuals with special needs, also, bear a particular burden. That is not to say that the burden is overwhelming or necessarily injurious, but it becomes one more challenge that has to be faced amidst life's other, more commonly occurring stress factors. With this in mind, it is not difficult to understand how the added stress brought on by personally living with a disability or caring for someone with a disability can lead to the development of anxiety disorders. Identifying the early signs of such a problem is critical so as to prevent the development of either serious or permanent consequences.

We must differentiate anxiety from that which is experienced as an appropriate response to a life situation. If, while you are on a safari, a lion wanders into your tent, fear is a highly appropriate and adaptive response. Intense, disabling fear in the absence of a lion is not adaptive. The anxiety disorder interferes with a person's natural and beneficial adaptive responses, and this interference can happen in varying degrees from mild to incapacitating. This article will describe six common types of anxiety disorder.

Generalized Anxiety Disorder (GAD) affects approximately four million adult Americans at any given time and is twice as common in women as in men. It usually is associated with other symptoms such as depression, alcoholism or another anxiety disorder. The day is spent worrying excessively about a variety of issues such as health, family, money, etc. While these are everyday worries for all of us, the person with GAD cannot "snap out of it." It is persistent and continues throughout the day and frequently into the night resulting in sleep difficulties. Patients with GAD startle easily. Symptoms such as fatigue, nausea, and tension are very common. Concentration is frequently impaired. When severe, the individual can be functionally incapacitated.

Panic Disorder is an intense fear with a sudden onset usually lasting 10 minutes or less. It is frequently associated with a rapid heartbeat, sweating and may even feel like a heart attack. These people frequently go to the emergency room because they believe they are having a heart attack but are not. It affects over two million people in the United States and again is twice as common in women as in men. It is usually associated with anticipatory anxiety in between the attacks. This anticipatory anxiety leads to avoidance. For example, if the person had an attack on an elevator, that person may well avoid elevators. It is not uncommon for people to become housebound because they fear going out on the street. The attacks are less common when the person is at home.

Obsessive-Compulsive Disorder (OCD) patients have uncontrollable thoughts and images that are highly disturbing. These thoughts and mental images are persistent and are very difficult to ignore, hence they are described as obsessive because the person cannot simply push them out of his or her mind. Some individuals find that if they perform motor rituals they can relieve the anxiety associated with the obsessions. These anxiety-reducing activities are referred to as compulsions and may involve activities such as hand-washing to avoid germs. It frequently involves checking to make sure the doors are locked or that the gas is turned off. OCD affects over three million adult Americans and is about as common in men as in women. This disorder starts early in life, including childhood and adolescence, and tends also to be progressive. When it is severe, it can be incapacitating.

Post-Traumatic Stress Disorder (PTSD) occurs in an individual who has been exposed to a traumatic event in which the person experienced or witnessed events that threatened death or serious injury. Furthermore, the person's response involved fear and helplessness. Both the experience and the response to the experience are necessary for the development of PTSD. There is a marked tendency for the event to be re-experienced mentally in an intrusive fashion which is difficult to control. This re-living of the experience is described as a flashback. The flashback is associated with intense psychological distress. Individuals frequently avoid situations which they associate with the event, for example, no longer riding on trains. Symptoms of increased arousal such as insomnia, irritability, poor concentration and exaggerated startle response are common. The condition must last at least a month and up to three months to be considered acute, and if it lasts for more than three months, it is considered chronic. There are also situations in which the onset of conditions occurs after a delay of six or more months following the event.

Specific Phobias are intense fears associated with an object or situation that poses little or no real danger. Phobias may include animals such as dogs or mice or can involve objects, places, heights, escalators, etc. In addition to being intense, phobias represent irrational fears of particular things. For example, an individual may be perfectly comfortable climbing a mountain but unable to go above the 10th floor of an office building. It is often simply easier for the individual to avoid the dreaded object than to try to deal with it. These are more common in women than in men at a ratio of 2 to 1 and affect approximately six millions adults in the United States. They usually appear in childhood or adolescence and tend to persist into adulthood.

Social Phobia involves intense anxiety and self-consciousness in every-day social situations. Individuals with social phobia have a very strong fear of being judged by others and are embarrassed by their own actions. When intense, social phobia can lead to marked isolation and withdrawal from society. When circumscribed to a specific situation, such as addressing a group, it is relatively easy to avoid the situation and suffer fewer adverse consequences. When it extends to being unable to be around people and going to work or school, it may be beyond the individual's capacity to cover it up and they thereby suffer serious consequences. Obviously, it can be very difficult to make and to hold onto friends in the presence of this kind of disorder. It affects over three million adult Americans with women and men being equally likely to have the condition. It too tends to start in childhood or early adolescence.

Treatment of anxiety disorders has two components that can be offered separately or in combination. They are medication and psychotherapy. Both approaches, alone or in combination, can be effective in most of the anxiety disorders, but specific phobias respond best to specific forms of psychotherapy where the person is gradually exposed to the feared object and learns to deal with the resulting distress. It is very important that the therapist is able to do a careful diagnostic evaluation to see what specific forms of anxiety disorder or disorders are involved. As indicated earlier, anxiety disorders are co-morbid with alcohol and/or drug abuse. These may be sufficiently severe as to warrant separate or even immediate treatment prior to taking on the problem of the anxiety disorder. Because medication can play a role in many of these illnesses, it is useful to seek out a psychiatrist as the professional involved in the treatment. Sometimes the psychiatrist may choose to work with a psychologist or counselor, but there is an advantage to having one person available for the total care. The choice of medication must be explained as well as the side effects and/or problems that may be associated with that medication.

A form of psychotherapy called cognitive-behavioral therapy (CBT) has been found to be very effective, particularly in panic disorders and social phobias. It helps people to change their thinking patterns so that they do not intensify their symptoms. An important part of CBT is to change people's reactions to anxiety-provoking situations. The gradual exposure of an individual to that which is feared can have a beneficial effect in reducing the intense anxiety associated with that exposure. With gradual repeated exposures, anxiety can often be diminished to the point that the patient is able to function normally.

The take-home message is that these are not trivial problems, but that they can be treated adequately and frequently successfully. At the very least, most people can benefit while some can be essentially freed of their pathology. There is no reason to suffer quietly when treatments are readily available in most communities. This is a particularly important message to those with disabilities and their families. Stress can be cumulative, and when it exceeds the ability of the individual to compensate, it can be destructive. While it is hoped that with time the stigmatization and isolation often associated with many disabilities will be diminished and/or eliminated and, as a byproduct, will lead to a reduction in anxiety disorders brought on by this stigmatization, that time is not yet upon us. Until then, knowing the signs of an anxiety disorder can be the first step in seeking treatment and getting on the road to managed and improved mental health.

Dr. Cancro joined the faculty of New York University School of Medicine in 1976 as Professor and Chair of the Department of Psychiatry. In 1982 he added the directorship of the Nathan Kline Institute for Psychiatric Research to his other responsibilities. His major academic interest has been in the psychoses and, in particular, schizophrenia. In addition to his academic record, he has been active in the World Psychiatric Association, founding their Section on Psychiatric Rehabilitation, and he has served as a consultant to the World Health Organization for a number of years. On the national level, Doctor Cancro has served as a consultant to the U.S. Secret Service, the Department of Justice, and the New York Yankees.

By Robert Cancro, M.D.