Anxiety Disorders
Anxiety is a universal experience that, in most cases, is adaptive. For example, worry about potential illness may serve to motivate you to eat better, exercise, or visit your doctor. The mechanisms for experiencing and expressing fear and anxiety are hard-wired into our brains and nervous systems. The physical aspects of panic, the so-called “fight or flight” syndrome, involve a rush of adrenaline and a host of physical changes that prepare the body for action. In an emergency situation, this physical preparation could provide you with the ability to do things that would normally be far beyond your capacity.
Problems arise, however, when fear and anxiety become associated with situations and circumstances that are not truly dangerous and thereby lose much of their adaptive function. The term anxiety disorder is used when fear and anxiety become detached from actual danger, become chronic, and interfere with day-to-day functioning.
As you read over the descriptions below keep in mind that, although there are differences among the various anxiety disorders, they also share much in common. You may find that that one of these categories seems to fit your symptoms and experiences, or you may find that you have most or all of the symptoms of several disorders.
It is also very common for symptoms of depression to be associated with anxiety disorders. In some cases the depression is primary and exists independent of an anxiety disorders. In most cases, however, symptoms of depression develop as a result of having an anxiety disorder and will usually remit with appropriate treatment for anxiety.
Cognitive-behavior therapy has been shown to be an effective treatment for each of these disorders. Information about treatment for anxiety disorders is provided in the Treatment section. If you have specific questions, feel free to email me at DrAl@draljerome.com.
topPanic disorder
Panic disorder is characterized by repeated unexpected panic attacks and the fear of having additional attacks. Panic attacks are brief (usually around 10 minutes or less) intense “bursts” of fear, that are accompanied by physical reactions such as sweating, difficulty breathing, tingling, stomach distress, dizziness, increased heart rate, etc.). Other common symptoms include a sense of detachment, fear of dying or "going crazy", and the fear of losing control. Panic attacks may be related to certain situations or they may seem to come out of the blue.
Although the majority of people experience at least one panic attack during their lifetime, most do not develop panic disorder. What typifies panic disorder, is a persistent fear or worry about having another panic attack. Most people with panic disorder become very focused on monitoring their own physical symptoms for signs that a panic attack may be beginning (e.g., increased heart rate, or sweating). This inner focus results in an over sensitivity to small (and normal) variations in physical symptoms.
When a symptom is detected, it may instantly trigger a negative thought (Oh no, another panic attack) or fear of a catastrophic outcome (I am having a heart attack), which leads to an increase in physical symptoms. This cycle can ramp up quickly into a full-blown panic attack.
Ongoing monitoring and fear of panic can result in a sense of always feeling anxious and “on edge.” Actively worrying about the possibility of further attacks is referred to as anticipatory anxiety. In some cases, anticipatory anxiety can be more distressing and cause more problems than the actual panic attacks themselves.
topPanic disorder with agoraphobia
Agoraphobia is avoidance of public places that occurs most often because of fear of having a panic attack. It is, in a sense, “fear of fear.” Agorophobia often develops after a series of panic attacks that occur “out of the blue.” As the panic attacks occur more frequently and in different locations, a fear of going anywhere "unsafe" (where a panic attack may occur) can result. Thus, it is common for a person with agoraphobia to avoid travel and stay close to home.
In addition to the panic cycle described above in the section on panic disorder, people with agoraphobia become keenly focused on detecting specific aspects of their environment that serve as cues or triggers for panic attacks. For example, it may appear that panic attacks occur typically in crowded places or, conversely, when alone in open spaces. Attempts to determine the most likely place for panic attacks to occur leads to ongoing evaluation of travel plans and avoidance of situations that seem to be most dangerous.
There is also a focus on items, rituals, or people that provide “safety” from panic attacks. For example, carrying medication, staying close to the door of a store, or traveling with a spouse or good friend may provide a sense of safety that allows for approaching places or situations that would otherwise be frightening.
Although relatively rare, Agoraphobia can occur without panic attacks, in which case it is a more general fear of certain public places.
topObsessive-compulsive disorder
People with OCD are plagued by persistent, distressing thoughts, fears, or images (obsessions) that they cannot control, and they engage in a variety of rituals (compulsions) to manage the obsessions or reduce the anxiety or tension that the obsessions produce.
Examples of common fears associated with OCD include fear of contamination or dirt, fear of making mistakes, fear of embarrassment, and fear of catastrophic events. Some common intrusive thoughts include thoughts of violence and harming oneself or loved ones, persistent thoughts with sexual content (often graphic or violent), and having thoughts that are prohibited by religious beliefs.
The obsessions and compulsions are tied together in a cycle of anxiety that can leave the OCD sufferer unable to function in his day-to-day life. An familiar example of OCD is the person who is obsessed with germs or dirt. The fear of contamination (obsession) leads to the compulsion of excessive hand washing that is meant to neutralize the anxiety caused by exposure to feared contaminants. An obsession with intruders breaking into the house may lead to locking and relocking doors many times before going to bed.
Distressing thoughts or images may lead to various rituals to try to distract oneself from experiencing them or to “neutralize” their negative content. Some examples include praying in response to sexual images or blasphemic thoughts; asking a parent or friend for reassurance in response to concerns about making mistakes or thinking “bad” thoughts; and calling loved ones in response to images or thoughts related to their being harmed.
People with OCD may also be preoccupied with order and symmetry or have difficulty throwing unneeded items away (hoarding). In some cases, there are no specific fears or thoughts that are experienced; rather, there is a sense of discomfort or inner tension that is only relieved by performing certain rituals. Some of these rituals may be mental (e.g., counting in certain patterns) and others may be certain behaviors or patterns of behaviors that can be simple (e.g., looking at items in a certain way or for a fixed period of time or touching things in a certain way) or complex (e.g., carrying out a complicated sequence of actions in a specific order). The term “not just right” is used to describe the inner feeling of discomfort and tension that precedes the performance of rituals in this type of OCD.
Performing rituals is not pleasurable, and it does not get rid of the discomfort of OCD. Although rituals may provide temporary relief from anxiety or discomfort, they return even stronger after some period of time. A good analogy for thinking about how this works is a mosquito bite. Scratching the bite provides temporary relief of the itch, but it also aggravates the bite and the itching is worse when it returns.
It is important to recognize that most people have odd thoughts from time to time, specific ways of doing certain things, or rituals that they perform over and over. What is different about OCD, is that obsessions and rituals are recurrent and distressing, causing significant interference with daily life. Most adults with OCD recognize that what they are doing is senseless, although some adults and many children may not realize that their behavior is out of the ordinary.
topOCD spectrum disorders
Disorders such as Tourette’s syndrome, tic disorders, trichotillomania (hair pulling), and skin picking disorders are sometimes considered to related to OCD. These disorders have many similarities with the types of OCD that were described above using the term “not just right.” People with these disorders often refer to an inner tension or discomfort that can be very difficult to describe as preceding the performance of tics, hair pulling, or skin picking.
topHoarding
Compulsive hoarding is defined as acquiring and keeping objects to such an extent that normal use of living space is impaired. Thus, hoarding is much different than simply having significant collections of items (e.g., sports cards, dolls, stamps, etc). Hoarding can be associated with a variety of psychological disorders, but is most commonly associated with obsessive- compulsive disorder (OCD). People with compulsive hoarding syndrome typically have immense difficulty throwing anything away because they view items as potentially valuable or for fear that they might need those items in the future. As a result of their inability to throw things away, their homes are often filled stuff that most people would not consider to be worth saving.
Three criteria differentiate normal collecting from compulsive hoarding. First, compulsive hoarding involves the acquiring and failure to discard items that appear to most people to be useless or of limited value. Second, living spaces become so cluttered that normal activities for which they are intended are not possible. Tables may be piled with clutter, chairs and couches inaccessible, and hallways stacked with boxes or bags of items. For example, the dining room table may be so stacked with clutter that it cannot be used for meals. Third, compulsive hoarding results in significant distress or impairment in functioning. Occupants of the home may be "paralyzed" by the clutter and unable to engage in normal household tasks. Social interaction is frequently limited because of the potential embarrassment of others discovering the degree of clutter in the home. In extreme cases, there may be dangerous conditions such as hazards for falling, significant fire hazard, unsanitary conditions, and inability to prepare food.
topGeneralized anxiety disorder
Generalized anxiety disorder is characterized by excessive worries about a variety of different circumstances or situations. People with GAD report that they spend a lot of time worrying about all kinds of negative events that may occur. They anticipate disaster and are overly concerned about many different sorts of issues, such as health, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety. All people occasionally worry about these topics, but people with GAD fixate on them and can’t get them out of their minds. They often spend hours worrying intensely about things that might happen in the future and find it difficult or impossible to “turn off” the worry.
Physical symptoms of GAD may include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes. When GAD is relatively mild, and anxiety is not overwhelming, people with GAD can function in their day-to-day lives. Although they don’t typically avoid specific situations because of their disorder, severe GAD can make it difficult to carry out the simple tasks of life.
topSocial anxiety/social phobia
The essence of social anxiety (called social phobia in DSM-IV) is a fear of being evaluated negatively by other people in social situations. Most people are somewhat self-conscious in some situations, and one of the most common fears reported in the general population is a fear of public speaking. Social anxiety, however, is more than just normal self-consciousness.
People with social anxiety are nervous, anxious, and afraid in many social situations. Attending a business meeting or going to dinner with other people can be very difficult and cause a great deal of discomfort. Physical symptoms such as sweating, shakiness, and rapid heartbeat are commonly reported, as are negative thoughts about performance and how others may perceive their performance.
One of the key features of social anxiety is a vicious cycle that develops around participation in social situations. Anticipation of a social situation leads to anxiety and worry about how well things will go. Entering the situation with heightened anxiety leads to physical symptoms and ongoing monitoring of thoughts and feelings (How do I feel? Can anyone tell I am anxious?), as well as monitoring of other peoples’ reactions to the performance (How am I doing? Did I say anything stupid? ). Negative appraisals (I screwed up!) then lead to increased symptoms and the whole cycle continues or even worsens. Ironically, focusing on symptoms and thoughts makes it difficult to interact in a spontaneous way and can lead to the very thing that is feared.
topFear of flying and other phobias
Phobias are fears of specific objects or situations. Fear of flying, fear of heights, fear of driving over bridges, fear of confined spaces, fear of animals (spiders, dogs, etc.) are common phobias. Sufferers may experience the whole range of fear and anxiety symptoms experienced in any of the other anxiety disorders, such as panic attacks, anticipatory anxiety, physical symptoms, and catastrophic thoughts. The main difference between phobias and other anxiety disorders is that the situations that provoke anxiety are more limited and, therefore, the symptoms tend to be less debilitating in the context of day-to-day life. However, that is not always the case. If you have to fly on a regular basis and have an overwhelming fear of flying, anticipatory fear and anxiety can be almost constant and have a very negative impact on your life.
topPost-traumatic stress disorder
Post-traumatic disorder (PTSD) occurs as a result of a traumatic life experience such as military combat, an automobile accident, devastating natural events such as earthquakes and hurricanes, or a mugging or rape. Being involved in or witnessing these sorts of traumatic experiences can result in intense and long-lasting episodes of fear, anxiety, and panic that can have a debilitating effect on day-to-day functioning. Many people with PTSD report that they experience “flashbacks.” Flashbacks are vivid recollections or dreams of the traumatic event, often accompanied by realistic images and intense emotions. Other symptoms of chronic anxiety such as panic attacks, headaches, and various physical symptoms are also commonly reported.
topHealth anxiety
Health anxiety involves a persistent fear that a serious medical condition exists, despite evidence to the contrary. People with health anxiety become preoccupied with the idea of illness and spend a great deal of time monitoring symptoms, going to doctors, and reading information about the illness (or illnesses) that they fear. Along with chronic pain and unexplained symptoms, negative thoughts, physical signs of anxiety, worry, and panic attacks are also frequently associated with health anxiety.