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Each year about one of ten people in the United States experiences an anxiety related disorder. Anxiety is a feeling of fear or dread, commonly accompanied by avoidance behaviors.
Normal anxiety is a passing emotion. To be classified as a psychiatric disorder, anxiety must be disabling and long-
- separation anxiety disorder (anxiety due to social separation)
- selective mutism (inability to speak in certain situations)
- specific phobia (uncontrollable fear of particular stimuli)
- social anxiety disorder (social phobia)
- panic disorder (panic attacks)
- agoraphobia (compulsive avoidance of open spaces or crowds)
- generalized anxiety disorder (constant or unfocused anxiety)
- substance/medication-induced anxiety disorder (reactions to drugs)
- anxiety disorder due to another medical condition (e.g. in response to a heart condition or cancer diagnosis)
- other specified conditions (where a patient meets most of the criteria for an above condition, but the doctor specifies one or more ways they do not)
- other unspecified conditions (when there is not yet enough clinical evidence to make a different categorization) [Adapted from Stein et al., 2014]
What do all the anxiety disorders have in common? How can they be different?
What each condition on the above list has in common is the symptom of excessive fear and anxiety, plus avoidance behaviors. The disorders differ from each other in:
- age of onset (the DSM-based list above is in order by typical age of onset, with separation anxiety first because it can occur in babies as well as later in life)
- precipitating situations or objects (such as the specific stimuli in phobias)
- different "cognitive ideation" or mental responses
Anxiety disorders are most common in adolescence. As with other psychiatric conditions like depression and autism, anxiety is a spectrum disorder and comes in varying degrees of severity. Even sub-threshold cases (not severe enough to merit psychiatric treatment) can be quite disturbing to an individual.
What is the difference between a psychiatric disorder and a sub-threshold version of the same disorder?
Obsessive-compulsive disorder was once considered an anxiety disorder. Now it is grouped with several other syndromes, including hoarding and excoriation or skin and hair picking.
Why create a new category? Researchers found that OCD, hoarding, trichotillomania (hair-pulling), and skin-
In each case, people suffer from a compulsion (an irresistible impulse). The conditions all respond to drugs that boost serotonin levels. We will discuss OCD on the next page.
Stress-induced disorders are also in a separate category in the DSM and ICD. These syndromes form a distinct group because all are triggered by external stress or trauma.
Stress disorders include PTSD (post-traumatic stress disorder) and bereavement (reaction to death of a loved one). Stress disorders are covered in a section devoted to the concept of stress, in Chapter 14.
Dissociative disorders such as fugue states and traumatic amnesia are listed immediately after stress disorders, in both DSM and ICD. This is to convey that dissociative disorders may be caused or made worse by stress. We discuss dissociative disorders in Part Four of this chapter.
Why were obsessive-compulsive and stress disorders moved to different categories? Why are dissociative disorders listed next to stress disorders?
Biological explanations of anxiety disorder center around the interactions of frontal lobe areas with the amygdala. In animal models, there is an alarm circuit between part of the frontal lobe (the dorsal medial prefrontal cortex) and the amygdala. When activated, it increases sensitivity to threatening stimuli (Kaster, Gryglewski and Lanzenberger, 2014).
This same circuit was mentioned when we discussed depression. A leading theory relates depression to animal responses to injury, because the depressive-type responses (social isolation, inactivity, non-reactivity to usually pleasant stimuli) are characteristic of wounded animals trying to recover their health.
Researchers have long known that anxiety is a risk factor for later depression. The two syndromes may represent different stages in the same process: over-activating the normally protective circuit between the amygdala and the frontal lobes, ultimately damaging the organism's ability to function.
Pharmaceutical treatments for anxiety will probably be able to target the exact circuitry involved, sometime in the future. Meanwhile, current anti-anxiety drugs work with severe cases, and cognitive behavioral therapy works with about half of sufferers. As with depression, a combination of pharmaceutical and psychotherapy treatments produces the most enduring results.
Brody (1983) described a typical panic attack:
Imagine yourself riding on a crowded bus on the way to work. Suddenly, out of the clear blue, your heart starts to pound, you can't catch your breath, you feel dizzy, disoriented, nauseated and panicky. You think you're going to die or go crazy.
What are panic attacks like?
Though your legs have turned to rubber, as soon as the bus stops you push your way out onto the street and start running, anywhere just to get away from the crowds. This is the third time in a month this has happened on your way to work.
You're terrified to think what might be wrong with you. One thing you do know is that you'll never take the bus to work again–if you dare go out at all.
Panic attacks sometimes lead to agoraphobia: a dread of going into crowds or public places. Dr. Donald Klein, a professor of psychiatry at Columbia University Medical Center, says "about 99 percent of agoraphobias start with nonspecific panic attacks."
Agoraphobia is fear of crowds or public spaces ("agora" is Greek for a public meeting place). Agoraphobia is an example of an avoidance behavior associated with an anxiety disorder, because it aimed at preventing the stimuli that can produce a panic attack.
What is agoraphobia?
DSM-5 lists panic attacks and agoraphobia separately, because panic attacks can be found in other syndromes, or they may occur on their own. Panic attacks affect nearly a million Americans, mostly women. They usually start in the teens or early twenties.
A variety of methods have been used to treat panic attacks, including traditional psychotherapy and the form of behavior therapy called desensitization, which succeeds with about 30 percent of all cases. Fear of flying, which causes sufficient anxiety for many people that they refuse to travel by airplane, can almost always be treated successfully with desensitization.
What are effective treatments for panic attacks?
Medication is useful for putting an immediate end to a panic attack when it is occurring. Beta-blockers and similar anti-anxiety agents control panic attacks in about 90 percent of cases.
How can therapies be combined in treatment?
Many clinicians feel that drug treatments and talking psychotherapy treatments are best used together in treating panic attacks. This is the same conclusion researchers have reached with depression and other anxiety-related disorders.
A drug can make a quick change in the patient's condition, while psychotherapy can address emotional issues, provide new cognitive strategies for re-appraising life situations, and help a person make positive adjustments in daily living.
Kaster, S., Gryglewski, G., & Lanzenberger, R. (2014) Imaging brain circuits in anxiety disorders. Lancet Psychiatry, 1, 251-252. https://dx.doi.org/10.1016/S2215-0366(14)70348-7
Stein, D. J., Craske, M. A., Friedman, M. J., & Phillips, K. A. (2014) (2014) Anxiety disorders, obsessive-compulsive and related disorders, trauma- and stressor-related Disorders, and dissociative Disorders in DSM-5. American Journal of Psychiatry. Retrieved from: https://ajp.psychiatryonline.org/
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