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An Overview
Of Anxiety Disorders
Jack D.
Maser, Ph.D.
National Institute of Mental Health
Fear and anxiety are a normal part of
life, even adaptive in many conditions. Who among us has not studied
for a test without some anxiety -- and scored better for it? Who has
not walked down a dark street in a high crime district without
mounting fear? Normal anxiety keeps us alert: it makes us question
whether we really have to walk down that street after all.
Mental health professionals are not concerned with normal anxiety.
Rather, they attend to fear and anxiety that has somehow gone awry;
that inexplicably reaches overwhelming levels; that dramatically
reduces or eliminates productivity and significantly intrudes on an
individual's quality of life; and for which friends, family and even
the patient can find no obvious cause.
Clinicians recognize about 12 relatively distinct subtypes of anxiety
disorder: Panic Disorder, with and without Agoraphobia; Agoraphobia
Without a History of Panic Disorder; Specific Phobia; Social Phobia;
Obsessive-Compulsive Disorder; Post-traumatic Stress Disorder; Acute
Stress Disorder; Generalized Anxiety Disorder; Anxiety Disorder Due to
a General Medical Condition; Substance-Induced Anxiety Disorder; and
Anxiety Disorder Not Otherwise Specified.
Frequently, these disorders are made more complex and difficult to
treat because they are accompanied by depression, substance abuse and
suicidal thoughts. Full definitions of each subtype may be found in
The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, (DSM-IV), American Psychiatric Association, 1994, but the
primary distinguishing features will be mentioned briefly here:
Panic Disorder -- Within 10 minutes, escalating fear develops into a
discrete period of intense discomfort accompanied by at least four of
13 somatic or cognitive symptoms. The afflicted individual believes
that he or she is having a heart attack and dying and often presents
to a hospital emergency room with this complaint.
with Agoraphobia -- Often recurrent panic attacks become associated
with the places in which they occur. As the person attempts to avoid
these places, either in the hope of not triggering an attack or not
having help available or being unable to escape, their freedom of
movement and lifestyle may become severely restricted.
without Agoraphobia -- Panic attacks occur, but without the
consequence of avoidant behavior.
Agoraphobia Without a History of Panic Disorder -- Persons with
limited Symptom Panic Attacks or some other symptom(s) that may be
incapacitating or embarrassing (e.g., loss of bladder control) may
lead to a pervasive avoidance of a variety of situations. Common
agoraphobic situations include being in a crowd, crossing a bridge, or
leaving home alone. If the person forces exposure to the feared
situation, it is only considerable dread.
Specific Phobia -- Excessive fear upon exposure to a specific object
or situation (but not of a panic attack or being embarrassed in a
social situation) is the hallmark of a Specific Phobia. When
confronted by such objects or events as elevators, funerals,
lightening storms, insects, or furry animals, phobic individuals
become extremely fearful. Specific phobias may also involve fear of
losing control, panicking, and fainting when confronted with feared
object. Adolescents or adults recognize the fear as unreasonable, but
can do little to stop it. Often the individual can lead a relatively
normal life by simple avoidance, and the diagnosis not made.
Social Phobia -- Social Phobics have a persistent fear of exposure to
possible scrutiny by others. They fear that they will do something or
act in a way that will be humiliating or embarrassing. While it is
normal to have some anxiety before an encounter with the boss or
before giving a speech, most people are not incapacitated and manage
to get through the ordeal. This diagnosis is only made if the
consequent avoidant behavior interferes with functioning at work or in
usual social situations or if the person is markedly distressed about
the problem.
Obsessive-Compulsive Disorder (OCD) --Recurrent, distressful
obsessions (thoughts) or compulsions can significantly interfere with
normal marital, social or work routines. The person usually recognizes
the unreasonableness of the behavior, and this fact adds to the
distress. However, resisting the obsession or compulsion means that
the anxiety will escalate rapidly to intolerable levels. It is easier
to give into the intrusive thought or to execute the behavior.
Post-traumatic Stress Disorder (PTSD) -- This clinical condition can
be traced to a definable, traumatic event in the individual's life. It
might have occurred in war time or after witnessing a shooting, being
a rape or street crime victim, or living through some natural
disaster. The experience must have produced intense fear, helplessness
or horror. Either shortly thereafter or at some later date, the person
may experience flashbacks, recurrent and intrusive recollections of
the event, feelings of detachment, guilt, sleep problems and a variety
of somatic symptoms.
Acute Stress Disorder -- Symptoms, similar to PTSD, that develop
within a month after exposure to an extreme traumatic stressor and are
time-limited between 2 days and 4 weeks define this disorder.
Generalized Anxiety Disorder (GAD) -- The individual presenting with
GAD reports uncontrollable excessive anxiety and worry, more days than
not, for at least a 6-month period. They are likely to feel constantly
"on edge" and tired, they complain of muscle tenseness, they may be
irritable and unable to concentrate, and their sleep pattern is
disturbed. The more life circumstances about which the individual
worries, the more likely the diagnosis.
Anxiety Disorder Due to a General Medical Condition -- Anxiety
symptoms can include those of GAD, panic attacks, or OCD, and these
must be directly linked to a general medical condition by the person's
history, physical examination or laboratory findings. The anxiety
symptoms likely to be atypical for age of onset, course, and family
history.
Substance-Induced Anxiety Disorder -- The clinical presentation of
this condition may resemble Panic Disorder, GAD, Phobia, or OCD, but
the full set of diagnostic criteria for even one of these disorders
does not have to be met. However, it is essential that the anxiety
symptoms be due to the direct physiological effects of a drug of
abuse, medication, or exposure to a toxin.
Anxiety Disorder Not Otherwise Specified -- A fair number of people
may be expected to fit this category. For example, the DSM-IV clinical
trials found a number of people with Mixed Anxiety-Depression (i.e.,
not meeting full diagnostic criteria for either). Others who fit this
category might be persons with symptoms of Social Phobia who also have
dermatological conditions, stuttering problems and Body Dysmorphic
Disorder.
The prevalence of these disorders is startling. At sometime during
their lives, nearly a quarter (24.9%) of the adult population in the
United States will have an anxiety disorder. Only substance-related
disorders are more common (26.6%). The National Comorbidity Survey
shows that the percentage is greatest for social and simple phobias
(13.3% and 11.3%) and less for Agoraphobia (5.3%), GAD (5.1%) and
Panic Disorder (3.5%) (Kessler et al., 1994). The lifetime prevalence
of OCD is 2.56%, according to the National Institute of Mental Health
(NIMH) - Epidemiological Catchment Area Study (Robins and Regier,
1991).
What is especially striking is how many times one or more of these
anxiety disorders occur with each other and with other mental
disorders, such as depression and substance abuse (Maser and Cloninger,
1990; Regier, et al., 1990). Nearly 60% of patients who are diagnosed
with OCD are later diagnosed with depression (Robins and Regier,
1991). Panic attacks are even found to co-occur frequently in
schizophrenic patients (Boyd, et al., 1984), although they are usually
overlooked by clinicians.
It is important that clinicians and patients recognize that effective
treatments are available. Phobias can be treated by behavioral
methods, while panic disorder can be treated with medication,
cognitive-behavioral therapy or both (see Wolfe and Maser, 1994).
Obsessive-Compulsive and Post-traumatic Stress Disorders are difficult
but hardly impossible to treat, and the symptoms can be markedly
reduced, if not eliminated. When the anxiety disorder is effectively
dealt with, drug abuse and secondary depression will also usually
decline.
Every year the NIMH spends many millions of dollars on research on the
causes and treatments of the anxiety disorders. As understanding of
the causes has grown, effective treatments have been developed.
Treatment allows afflicted individuals to return to relatively normal,
productive lives. Recognition that something is wrong is what brings
people to this site on National Anxiety Disorders Screening Day. They
need to know that once identified, anxiety disorders can be treated.
References
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition). Washington,
D.C.: The American Psychiatric Press, 1994.
Boyd, J.H., Burke, J.D., Gruenberg, E.M., et al. Exclusion criteria of
DSM-III: A study of co-occurrence of hierarchy-free syndromes.
Archives of General Psychiatry. 1984; 41:983-989.
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M.,
Eshleman, S., Wittchen, H.-U., and Kendler, K.S. Lifetime and 12-month
prevalence of DSM-III-R psychiatric disorders in the United States.
Archives of General Psychiatry. 1994; 51:8-19.
Maser, J.D. and Cloninger, C.R. (Eds.) Comorbidity of Mood and Anxiety
Disorders. Washington, D.C.: The American Psychiatric Press, 1990.
Regier, D.A., Farmer, M.E., Rae, D.S., et al. Comorbidity of mental
disorder with alcohol and other drug abuse. Journal of the American
Medical Association. 1990; 264:2511-2518.
Robins, L.N. and Regier, D.A. Psychiatric Disorders in America. New
York: The Free Press, 1991.
Wolfe, B.E. and Maser, J.D. (Eds.) Treatment of Panic Disorder: A
Consensus Development Conference. Washington, D.C.: The American
Psychiatric Press, 1994. |
