The Anxiety Disorders
In This Chapter
- What a diagnosis really means
- Anxiety disorders and related conditions
- What these disorders do—and don’t—have in common
- Getting support from friends and family
I’m going crazy. I can’t breathe. I’ve got to get out of here. I know the doctors have missed something; maybe I have AIDS! I’d rather die than get up in front of that group … . I can’t turn off these thoughts racing around and around in my head.
This is the world of anxiety. Unless you’ve suffered from it, it can be quite difficult to understand how someone’s life can be so affected by what may appear quite trivial. Unfortunately, a lot of people have firsthand experience; anxiety disorders plague 40 million people in the United States alone.
However, whereas all anxiety disorders share certain features, there are differences across conditions. In this chapter, we take a look at each clinical anxiety disorder, find out what an anxiety disorder diagnosis really means, and learn how to translate a terrifying experience into something your friends and family members can understand.
Sam goes to his doctor complaining of chest pains, shortness of breath, trouble sleeping, and irritability. His symptoms began after a divorce and escalated after he got a welcome yet stressful promotion at work. His brother, Max, goes to his doctor with an arm injury he received in a flag-football game. Max’s doctor does an x-ray and easily diagnoses a broken arm. Ten other physicians could perform the same test and would reach the same conclusion. Unfortunately, this isn’t the case for Sam.
Sam’s mental state is a changeable collection of thoughts, physical symptoms, and feelings. Though anxiety disorders clearly have a physical basis, the doctor can’t x-ray his mind, and other kinds of brain imaging are not helpful for diagnosis. Sam’s diagnosis is likely to be made by default; the doctor may do several tests to rule out easy-to-measure physical problems and essentially conclude that Sam’s problem involves his brain. How sensitively and knowledgably the doctor communicates this will depend upon his or her beliefs about the cause/nature of mental illness.
ON THE CUTTING EDGE
A 2004 study found that 25 percent of 9,000 randomly interviewed Americans met the criteria for a mental illness within the past year; fewer than half of those in need had gotten treatment.
The Pros and Cons of Labels
When considering anxiety disorder diagnoses, it’s important to keep in mind what they’re good for and what they aren’t.
For instance, a diagnostic label can provide a useful shortcut for describing (and making sense of) a collection of thoughts, feelings, and behaviors that tend to go together. It can be reassuring to know that there’s a name for this terrifying, imprisoning experience, that other people have had—and gotten better from—similar illnesses, and that there are doctors out there who’ve treated similar problems. That is, we are not alone.
On the other hand, although a diagnosis can tell us what we have; we should never let it tell us who we are. When you get an anxiety disorder diagnosis, take all the benefits you can from the structure, clarity, and reassurance it can provide—and take heart in the route to recovery it reveals. But don’t let it be a confining and limiting label or think of it as a precise analysis encompassing everything about your unique human experience.
ON THE CUTTING EDGE
Anxiety often accompanies depression, and an addiction may accompany a mood or anxiety disorder. Unfortunately, even though 50 percent of people with one mental disorder also meet the criteria for a second, research suggests that mental-health treatment is often geared toward a single problem or disorder.
Co-occurrence
An obstacle to the “right” diagnosis is the fact that disorders often coexist with each other; 58 percent of patients diagnosed with one anxiety disorder also meet the criteria for a second. A person diagnosed with panic disorder may also suffer from agoraphobia; he or she may also show signs of depression and social anxiety.
Zeroing in on—and treating—one disorder may bring partial relief but not address the whole problem. For example, an antidepressant may significantly reduce panic symptoms but inadequately address the crippling avoidance that limits careers and puts love lives on hold. In terms of treatment, then, a diagnosis is a great starting point, but ideally the finish line should be clear of any limits our anxiety disorder is currently imposing on our lives.
Difficulty with Objectivity
Another challenge with diagnosing a mental condition is the fact that the source of our symptoms (the brain) is also the source of information about those symptoms. Max’s mind should be able to clearly recall and describe the circumstances surrounding his injury, but Sam may not be able to be so objective. Asking a distressed mind to calmly describe itself can be like asking a ball of wool to unravel itself.
STRESS RELIEF
Tracking symptoms (noting time, length, triggers, and so on) on a daily basis can not only help our doctors make better diagnoses, it can help us get some distance from our anxiety symptoms. In addition, loved ones can sometimes provide essential information to doctors, so we often encourage patients to bring loved ones along to appointments, especially early in the diagnostic process.
Cultural Differences
Finally, cultural differences can get in the way of a clear and objective diagnosis. Although people of all races, cultures, and social classes experience anxiety disorders, there are cultural differences in how individual symptoms are regarded and expressed.
Cultural differences in emotional expression and social behavior can be misinterpreted as “impairments” if clinicians are not sensitive to the cultural context and meaning of exhibited symptoms. For example, in some cultures, it is normal and natural to channel stress symptoms into physical complaints. In the United States, however, this tendency is sometimes frowned upon by physicians. In turn, these physicians may not have the sensitivity or knowledge to effectively communicate that the problem is anxiety related.
On the other hand, serious emotional distress can be overlooked if the person’s description or behavior doesn’t match what the physician expects. In some Native American languages, there is no equivalent translation for anxiety; savvy clinicians have to rely more on descriptions of stressful events. Similarly, several studies have shown that Asian Americans tend to report feeling more social anxiety in comparison to numerous other groups; however, in these studies, Asian Americans were much less likely to avoid socially uncomfortable situations or show behaviors that many clinicians would look for in diagnosing social anxiety disorder. Absent the anticipated outward signs, the internal turmoil might be missed.
STRESS RELIEF
Choosing a mental health professional who is culturally similar to you—or who has worked extensively with members of your culture—can reduce misdiagnosis or mistreatment.
Now that we have some perspective on what an anxiety disorder diagnosis means, let’s take a look at the anxiety disorders listed in the fifth edition of the Diagnostic and Statistical Manual. You’ll see that the anxiety disorders have a lot in common; for instance, they all involve chronic or difficult-to-control fear; numerous physical symptoms; and a strong desire to avoid/escape uncomfortable situations. However, they’re also unique; the sudden spontaneous terror of a panic attack may be completely unfamiliar to someone with generalized anxiety disorder.
Generalized Anxiety Disorder: Chronic Worry
At some point, most of us have worried about a child who’s out later than usual, stressed over a dwindling bank account, or imagined that a minor illness was a symptom of a more serious one. During times of stress, it’s pretty normal to find ourselves stewing over things we can’t control.
For the 4 million Americans suffering from generalized anxiety disorder (GAD), worry is a daily companion. Even if sufferers realize their anxiety is more intense than the situation warrants, they just can’t seem to shake it. Not surprisingly, a constant, low-level state of fear takes its toll, leading to physical symptoms such as headaches, muscle tension, stomach problems, and a disrupted sleep pattern. Over time, these can wear a person down, making life a tiring, uphill series of events.
ANXIETY ATTACK
GAD is diagnosed if symptoms are present for more days than not during a period of at least six months. The symptoms also must cause substantial distress or interfere with daily life.
In the 1990s and 2000s, Drs. Robert Spitzer, Janet B. Williams, Kurt Kroenke, and colleagues developed the Patient Health Questionnaire (PHQ), in an effort to help primary physicians identify and treat common mental illnesses in their patients. Materials are freely available online (phqscreeners.com/overview.aspx), with the following language: “No permission required to reproduce, translate, display or distribute.”
The following questionnaire, the GAD-7, is useful to screen for GAD and monitor symptoms over time. If relevant for you, feel free to make as many copies as you’d like for monitoring purposes.
Over the last two weeks, how often have you been bothered by any of the following problems?
In order to rate the severity of generalized anxiety symptoms, count each symptom rated “1” (“several days”) once, each rated “2” (“more than half the days”) twice, and “3” (“nearly every day”) three times (i.e., symptoms rated “2” or “3” should be multiplied by 2 or 3). A total score of 5 to 9 indicates mild generalized anxiety symptoms; 10 to 14, moderate symptoms; and 15 or more, severe symptoms. Put another way, a score of 10 to 14 draws attention to a possible clinically significant condition, while a score of 15 or more indicates that treatment is probably warranted.
Note that, besides restlessness, tiredness, and muscle tension/aches (including headaches), many people with generalized anxiety experience other physical symptoms, such as sweatiness, nausea, frequently needing to use the bathroom, and even trembling.
Also, people with generalized anxiety tend to see potential problems as more likely and more catastrophic than others do, and they are sometimes jumpy or easy to startle.
Up to a quarter of people with GAD develop an additional anxiety disorder. GAD sufferers may, for example, choose to stay at home—a place of safety—as in agoraphobia. Or they may avoid social contact, as in social anxiety disorder.
Experience has shown that professional treatment can have a positive impact on GAD. In addition, sufferers can take some action to control some of their symptoms, as you will see later in this book.
Social Anxiety Disorder: Beyond Butterflies
James was always a little shy in elementary school. He described himself as “excruciatingly self-conscious” during his teen years. However, after joining the military, with its built-in social network, he thought his shyness was a thing of the past. Until he left the army and his marriage failed.
His civilian job required interaction with new people on a regular basis, and James found it increasingly difficult to put on his game face. When he was asked to give a presentation, he stressed about it for days and finally called in sick. He began avoiding the lunchroom and felt increasingly self-conscious in meetings. By the time he finally got help, he had passed up at least two promotions and had become so lonely and isolated he was experiencing fleeting thoughts of suicide.
ON THE CUTTING EDGE
A 2006 study found that people suffering with social anxiety disorder have increased activity in a part of the brain when confronted with threatening faces or frightening social situations. Though methods of imaging brain activity are currently quite expensive and of limited usefulness for individual patients, they may eventually be feasible to help objectify how severe a person’s social phobia is, as well as the effectiveness of treatments.
As you can see, there’s a quantitative difference between social anxiety disorder—also called social phobia—and the nervousness many of us feel when asked to speak at a conference or give a wedding toast. A phobia of public speaking is the most common form of social anxiety disorder, and this phobia can cause substantial suffering and missed opportunities. However, many people with social anxiety disorder can become afraid of everyday social interactions such as shopping or going to a party with co-workers. Over time, this anxiety perpetuates itself, resulting in …
- Extreme self-consciousness in social settings.
- A strong urge to avoid social interaction.
- An excessive fear of looking or sounding foolish in front of people.
Although we can all feel shy at times, particularly among strangers or when we are asked to perform a task in front of others, social phobia is normally diagnosed when these shy feelings become almost overwhelming, accompanied by physical symptoms of extreme nervousness, and when these symptoms begin to impact a person’s ability to function socially.
MYTH BUSTER
“Social phobia is just shyness.” This is an oversimplification. Moderately shy individuals don’t stress about an upcoming social event for weeks, sweat, tremble, and feel terrified during it, or take drastic measures to avoid it. Though our temperaments can influence the likelihood of developing social phobia, being shy doesn’t mean we can never enjoy social activities.
Panic Disorder: The Tsunami of Anxiety
It’s virtually impossible to do justice in describing the terror and fear involved in a panic attack; if you’ve had one, you know what it’s like; if you haven’t, it can be hard to imagine. A panic attack is a sudden episode of overwhelming fear and anxiety, with accompanying physical sensations and/or thoughts.
ANXIETY ATTACK
The frightening sensations of a panic attack typically peak within 10 minutes; our bodies can’t sustain that level of anxiety and fear for much longer.
Not everyone who has experienced severe anxiety, including panic attacks, has panic disorder. That is, panic disorder is defined as having more than one spontaneous or out-of-the-blue panic attack, along with negative effects of this spontaneous anxiety on a person’s life.
The Patient Health Questionnaire includes a panic disorder section that can be helpful in establishing the diagnosis:
Questions about anxiety.
Think about your last bad anxiety attack.
If a person responds “yes” to all 4 of the “questions about anxiety” and “yes” to at least 3 accompanying symptoms during their last bad anxiety attack, that person is likely to have panic disorder.
Note that some people with panic disorder have other symptoms. For example, it’s common to feel a sense of impending doom (something terrible is about to happen) with a panic attack. Also, panic attacks can be accompanied by a feeling of losing control or “going crazy.” Finally, some people have odd perceptual experiences during panic attacks, including the sense that the environment around them is not real or that they are outside their bodies.
Given this bombardment of bodily sensations, no wonder a panic attack can make someone feel as if the world is coming apart. And it can happen anywhere. Sometimes panic sufferers experience attacks truly out of the blue. Other times they will have attacks in certain situations (for example, in crowded restaurants).
Not all panic attacks develop into panic disorder. Some people have one panic attack and never experience another one. Some have a few that get better or worse as life stressors change. When a person has suffered at least two unexpected panic attacks—and at least a month of fear and worry over having another one—a clinical diagnosis is likely. Even then, a sufferer may develop coping routines to avoid extreme stress, such as leaning on family or friends. Regularly calling and getting together with friends, for example, can be helpful in managing everyday stress. Staying connected like this is good in the long run, too; research shows that people are less likely to have panic symptoms when they feel cared for by friends and family.
MYTH BUSTER
“Years of suffering requires years of therapy.” Actually, guidelines among therapists now call for improvements to be noticeable within 6 weeks. And studies show that 70 to 90 percent of patients with panic disorder can be helped with treatment.
For some people, particularly when such support isn’t available, the only option apparent to them is to withdraw from society—which is called agoraphobia.
Agoraphobia: Fear of the Marketplace
Literally meaning “fear of the marketplace,” agoraphobia is an anxiety disorder whose sufferers sometimes feel that the only safe place is home. In a sentence, agoraphobia is a fear of being in a situation or a place from which there is no easy escape. The clinical definition of agoraphobia is marked fear or anxiety in two or more of the following types of situations:
- Public transportation like buses and planes
- Open spaces like marketplaces and bridges
- Enclosed places like shops and theaters
- Being in lines or crowds
- Being outside of the home alone
A person with agoraphobia fears/avoids these situations because they are difficult to escape, or help might not be available if the person becomes incapacitated or develops embarrassing symptoms. Patients with agoraphobia often find that being in such situations is tolerable if they are with a trusted companion; however, it is not always easy on family members, etc., to be available.
Panic disorder and agoraphobia are strongly related. Though people with these kinds of situational fears have not always experienced panic attacks, it is clear that panic attacks can trigger or acutely worsen agoraphobia. A person feels insecure, worried about another attack, and even though there may be no evidence that further attacks will happen or happen anywhere other than a specific place, a person may begin to feel that the home is their only safe haven.
A tendency to develop agoraphobia can run in families and apparently has a genetic basis. Nevertheless, effective treatments have been found to significantly reduce the symptoms. These include cognitive behavioral therapy, medications, and lifestyle changes, which we discuss later.
ANXIETY ATTACK
The quicker a person gets treatment for an anxiety disorder, the better the odds of improvement. However, all persons with anxiety disorders can get better.
Specific Phobia: Targeted Fear
Melissa, age 40, loves visiting family on the east coast. Each year she makes the trip from her home in Santa Monica, driving the more than 2,500 miles, making stops on the way to refuel and rest. Though she knows the trip would take a fraction of the time by air, she can’t bring herself to even visit an airport. Melissa has a phobia of flying. Unlike a person with agoraphobia, she doesn’t fear being stuck high in the air and unable to escape; she fears crashing.
Unlike general anxiety, a specific phobia is triggered by a specific inciting factor—dogs, heights, or confined spaces. More than six million Americans suffer from such phobias, and although in many cases a phobia isn’t a serious condition (in that it doesn’t always interfere with everyday life), some phobias can limit or control a person’s behavior.
Remember Indiana Jones, fearless hero and adventurous archeologist? Indy had one chink in his armor—his phobia of snakes. Phobias have nothing to do with bravery or rational logic—the strongest, most intelligent people can suffer from phobias.
Related Conditions
Until recently, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) were considered anxiety disorders, and many experts argue that there are good reasons for that. However, there are also advantages to considering these conditions and their other close cousins separately. In this book, we note that OCD and PTSD share some features in common with the anxiety disorders just introduced, and we note that some of the principles outlined throughout the book are also relevant to OCD and PTSD. In addition, we felt it was important to discuss depression as well, as anxiety disorders and depression tend to co-occur within persons and within families.
Obsessive Compulsive Disorder: The Broken Record
Here’s Mark’s story:
During the third grade, I started having unusual symptoms. I kept having vivid, unwanted thoughts and images—horrible things such as killing a family member. I worried that I had actually done something terrible, and felt trapped, unable to escape the thoughts. I couldn’t stand to be around knives, and I insisted that my parents put them away in drawers. My parents eventually brought me for treatment and, with the help of medication and a great therapist, I began getting control over my thoughts, feelings, and behaviors. I was amazed to discover how many other people were suffering from OCD … . OCD was the most terrible experience of my life, but in some ways it hasn’t been all bad—I am now more confident, and I can really understand how other people feel.
You know how it feels to worry that you didn’t lock the door or turn off the stove before leaving home. You’ve probably had the sudden impulse to do something irrational or out of character. Although many people can choose to ignore or override such doubts, about 2 percent of the U.S. population finds these compelling thoughts or urges impossible to ignore, ultimately setting in motion a repetitive, energy-draining cycle of behavior aimed at controlling and reducing the emotional discomfort. This repetitive cycle is often obsessional thoughts followed by repetitive actions that are geared toward managing or alleviating them.
An obsession is an unwanted thought, image, or urge that intrudes into consciousness. A person may experience upsetting thoughts, repugnant sexual images, concerns about germs or contamination, or unwanted urges to harm himself or loved ones. A compulsion is an overwhelming urge to do something, often in response to obsessive thoughts. For example, some people wash their hands excessively in an attempt to reduce anxiety about germs. Others feel compelled to count objects in a certain way to reduce anxiety. The compulsion—or behavior—is a response to the anxious feeling.
For example, an OCD sufferer may feel compelled to repeat actions, checking things even though rationally they know there is no need. For some, the disorder can take forms that others cannot easily observe. A person may compulsively monitor their own breathing or avoid certain numbers or colors.
Unfortunately, although persons with OCD may receive a feeling of temporary relief from performing compulsions, sufferers report that such relief is short lived. With passing time, or in the right circumstances, the feelings of insecurity heighten again.
Post-Traumatic Stress Disorder: The Endless Movie
Mike can’t sleep. He tells his doctor he feels dazed and numb, as if he’s in another world. Loud noises make him jump, and he has this constant undercurrent of fear. He starts to cry as he explains how his relationship to his wife and children is becoming strained by his behavior.
Three weeks ago, Mike witnessed his friend accidentally shoot himself in a hunting accident. Two days later, his symptoms became pronounced. At present, Mike is suffering with acute stress disorder, an emotional condition that can emerge after a person has either witnessed or experienced death, serious injury, or sexual violence. If his symptoms continue for more than a month, his diagnosis will become post-traumatic stress disorder. Its symptoms include the following:
- Reliving the event through unwanted memories, nightmares, flashbacks (the sensation that the event is occurring now), or intense distress or physical reactions to reminders of the event
- Avoidance of thinking about or reminders of the event
- Changes in thoughts and mood (e.g., thoughts that the world is more dangerous than is the case, less interest in activities that used to be enjoyable)
- Hyperarousal (e.g., difficulty sleeping, a tendency to startle easily, trouble concentrating, and a general sense of restlessness and being on edge)
Whereas any of us would be extremely upset following a life-threatening trauma such as a serious car accident, rape, or a life-threatening illness, for many of us the symptoms would lessen considerably over time. Our risk for this disorder goes up or down depending upon the severity of the trauma and our own personal tendencies, and some experts believe that symptoms persist, at least in part, because of avoidance. That is, if a person is able to “talk out” and process what happened, and if they “get back on the horse of life” (continue their normal everyday activities and don’t run away with drugs and alcohol), the symptoms will decrease with time.
ON THE CUTTING EDGE
Until recently, mental health professionals didn’t realize that patients who survive critical illnesses and intensive-care unit treatment are at relatively high risk for post-traumatic stress disorder. Critically ill patients often have horrific memories of being out of control and confused, with frightening experiences of being tortured, etc.
Depression: Churchill’s Black Dog
In Chapter 1, we mentioned that Winston Churchill suffered from anxiety, but he also famously suffered from clinical depression, which he referred to as his “black dog.” Those of us with anxiety disorders are at increased risk for major depressive episodes as well, especially without treatment. Often, but not always, anxiety disorders emerge earlier than depressive episodes.
The Patient Health Questionnaire includes a depression section that can be helpful in establishing the diagnosis and monitoring symptoms over time. This section is often referred to as the PHQ-9. If relevant for you, feel free to make as many copies as you’d like for monitoring purposes.
Over the last two weeks, how often have you been bothered by any of the following problems?
To rate the severity of depressive symptoms, count each symptom rated “1” (“several days”) once, each rated “2” (“more than half the days”) twice, and “3” (“nearly every day”) three times (i.e., symptoms rated “2” or “3” should be multiplied by 2 or 3). A total score of 5 to 9 indicates mild depressive symptoms; 10 to 14, moderate symptoms; and 15 or more, severe symptoms. Put another way, a score of 10 to 14 draws attention to a possible clinically significant condition, while a score of 15 or more indicates that treatment is probably warranted.
Anxiety’s Effects on Others
Because anxiety disorders affect the way we feel, think, and act, our friends and family may be affected by them, too. Maybe we’ve canceled plans with a friend because of our fears, or our anxiety has made us on-edge and irritable. Now that we know what the problem is, how can we explain our anxiety disorder to others in a way that makes sense and allows us to get the support we need?
Friends and family can be supportive only if they know about a problem. At the same time, no magic words can guarantee a positive response; no matter how you say it, some people will be judgmental or skeptical. Most of the people we care about will be supportive of our attempts to get better; they may be less so if they think we’re using our diagnosis as an excuse to justify a short fuse or continue avoiding things we’re afraid of.
The trick is to prepare in advance, being clear with yourself about why you are telling the person, what you want from him or her, and how you will respond to whatever reaction they might have. For example, before talking to a friend or family member about your anxiety disorder, ask yourself the following:
Why do I want or need to tell this person? If you’re telling your boss, for example, you should probably stick to how it impacts work, what help or assistance you need, and what you are doing to get better.
What do I want from him or her? For instance, do you want emotional support or do you want this person to participate in your treatment?
How has this person responded to other challenges in the past? How does the person handle his or her own emotional bumps and bruises?
Write down what you want this person to know about your anxiety disorder. In addition to telling your own story, it can be useful to find some basic reading material you can recommend they use as a reference. Don’t sabotage yourself by sharing with your loved one when you’re in the middle of an argument, when either of you is pressed for time, or when either of you is in a bad mood.
ANXIETY ATTACK
Before sharing the fact that you have an anxiety disorder with anyone at work, be sure you know why you are doing it, what the possible consequences are, and what legal rights you have.
Now that we’ve met the anxiety disorders and related conditions, remember what we discussed about diagnosis. These lists of symptoms represent psychiatry and psychology’s best attempt to summarize conditions that affect real people. Your experience will be unique, and your path to emotional freedom will be your own; in later chapters, we discuss what the best self-help and professional assistance have to offer.
But before we get to problematic symptoms, let’s take a look at the “why” behind the “what.” An anxiety disorder diagnosis often raises as many questions as it answers. Why me? Why do only some people develop anxiety disorders? Is it nature (biology) or nurture? In the next chapter, we discuss the causes of anxiety disorders: the genetics, the biology, the environment, and the internal triggers that either cause them or keep them going.
The Least You Need to Know
- All anxiety disorders share an undercurrent of fear, various physical symptoms, and attempts to avoid.
- An accurate diagnosis of any mental condition is challenging because it is based on self-report, symptoms often change, and cultural influences may cloud the picture.
- Obsessive compulsive disorder, post-traumatic stress disorder, and depression can be considered anxiety-related conditions.
- Family support can be critical in overcoming an anxiety disorder. Before talking with loved ones, it is helpful to know why you want to share with them and how you’d like them to help you.