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Anxiety
Disorders
Introduction
Everybody
knows what it's like to feel anxious – the butterflies
in your stomach before a first date, the tension you
feel when your boss is angry, the way your heart pounds
if you're in danger. Anxiety rouses you to action. It
gears you up to face a threatening situation. It makes
you study harder for that exam, and keeps you on your
toes when you're making a speech. In general, it helps
you cope.
But
if you have an anxiety disorder, this normally helpful
emotion can do just the opposite – it can keep
you from coping and can disrupt your daily life. Anxiety
disorders aren't just a case of "nerves."
They are illnesses, often related to the biological
makeup and life experiences of the individual, and they
frequently run in families. There are several types
of anxiety disorders, each with its own distinct features.
An
anxiety disorder may make you feel anxious most of the
time, without any apparent reason. Or the anxious feelings
may be so uncomfortable that to avoid them you may stop
some everyday activities. Or you may have occasional
bouts of anxiety so intense they terrify and immobilize
you.
Anxiety
disorders are the most common of all the mental disorders.
At the National Institute of Mental Health (NIMH), the
Federal agency that conducts and supports research related
to mental disorders, mental health, and the brain, scientists
are learning more and more about the nature of anxiety
disorders, their causes, and how to alleviate them.
NIMH also conducts educational outreach activities about
anxiety disorders and other mental illnesses.
Many
people misunderstand these disorders and think individuals
should be able to overcome the symptoms by sheer willpower.
Wishing the symptoms away does not work – but there
are treatments that can help. These pages are meant
to help you understand these conditions, describe their
treatments, and explain the role of research in conquering
anxiety and other mental disorders.
Generalized
Anxiety Disorder
"I
always thought I was just a worrier. I'd feel keyed
up and unable to relax. At times it would come and go,
and at times it would be constant. It could go on for
days. I'd worry about what I was going to fix for a
dinner party, or what would be a great present for somebody.
I just couldn't let something go."
"I'd
have terrible sleeping problems. There were times I'd
wake up wired in the morning or in the middle of the
night. I had trouble concentrating, even reading the
newspaper or a novel. Sometimes I'd feel a little lightheaded.
My heart would race or pound. And that would make me
worry more."
Generalized
anxiety disorder (GAD) is much more than the normal
anxiety people experience day to day. It's chronic and
exaggerated worry and tension, even though nothing seems
to provoke it. Having this disorder means always anticipating
disaster, often worrying excessively about health, money,
family, or work. Sometimes, though, the source of the
worry is hard to pinpoint. Simply the thought of getting
through the day provokes anxiety.
People
with GAD can't seem to shake their concerns, even though
they usually realize that their anxiety is more intense
than the situation warrants. People with GAD also seem
unable to relax. They often have trouble falling or
staying asleep. Their worries are accompanied by physical
symptoms, especially trembling, twitching, muscle tension,
headaches, irritability, sweating, or hot flashes. They
may feel lightheaded or out of breath. They may feel
nauseated or have to go to the bathroom frequently.
Or they might feel as though they have a lump in the
throat.
Many
individuals with GAD startle more easily than other
people. They tend to feel tired, have trouble concentrating,
and sometimes suffer depression, too.
Usually
the impairment associated with GAD is mild and people
with the disorder don't feel too restricted in social
settings or on the job. Unlike many other anxiety disorders,
people with GAD don't characteristically avoid certain
situations as a result of their disorder. However, if
severe, GAD can be very debilitating, making it difficult
to carry out even the most ordinary daily activities.
GAD
comes on gradually and most often hits people in childhood
or adolescence, but can begin in adulthood, too. It's
more common in women than in men and often occurs in
relatives of affected persons. It's diagnosed when someone
spends at least 6 months worrying excessively about
a number of everyday problems.
In
general, the symptoms of GAD seem to diminish with age.
Successful treatment may include a medication called
buspirone. Research into the effectiveness of other
medications, such as benzodiazepines and antidepressants,
is ongoing. Also useful are cognitive-behavioral therapy,
relaxation techniques, and biofeedback to control muscle
tension.
Panic
Disorder
"It
started 10 years ago. I was sitting in a seminar in
a hotel and this thing came out of the clear blue. I
felt like I was dying."
"For
me, a panic attack is almost a violent experience. I
feel like I'm going insane. It makes me feel like I'm
losing control in a very extreme way. My heart pounds
really hard, things seem unreal, and there's this very
strong feeling of impending doom."
"In
between attacks there is this dread and anxiety that
it's going to happen again. It can be very debilitating,
trying to escape those feelings of panic."
Panic
Attack Symptoms
Pounding
heart
Chest pains
Lightheadedness or dizziness
Nausea or stomach problems
Flushes or chills
Shortness of breath or a feeling of smothering or choking
Tingling or numbness
Shaking or trembling
Feelings of unreality
Terror
A feeling of being out of control or going crazy
Fear of dying
Sweating
People with panic disorder have feelings of terror that
strike suddenly and repeatedly with no warning. They
can't predict when an attack will occur, and many develop
intense anxiety between episodes, worrying when and
where the next one will strike. In between times there
is a persistent, lingering worry that another attack
could come any minute.
When
a panic attack strikes, most likely your heart pounds
and you may feel sweaty, weak, faint, or dizzy. Your
hands may tingle or feel numb, and you might feel flushed
or chilled. You may have chest pain or smothering sensations,
a sense of unreality, or fear of impending doom or loss
of control. You may genuinely believe you're having
a heart attack or stroke, losing your mind, or on the
verge of death. Attacks can occur any time, even during
nondream sleep. While most attacks average a couple
of minutes, occasionally they can go on for up to 10
minutes. In rare cases, they may last an hour or more.
Panic
disorder strikes between 3 and 6 million Americans,
and is twice as common in women as in men. It can appear
at any age – in children or in the elderly –
but most often it begins in young adults. Not everyone
who experiences panic attacks will develop panic disorder
– for example, many people have one attack but
never have another. For those who do have panic disorder,
though, it's important to seek treatment. Untreated,
the disorder can become very disabling.
Panic
disorder is often accompanied by other conditions such
as depression or alcoholism, and may spawn phobias,
which can develop in places or situations where panic
attacks have occurred. For example, if a panic attack
strikes while you're riding an elevator, you may develop
a fear of elevators and perhaps start avoiding them.
Some
people's lives become greatly restricted – they
avoid normal, everyday activities such as grocery shopping,
driving, or in some cases even leaving the house. Or,
they may be able to confront a feared situation only
if accompanied by a spouse or other trusted person.
Basically, they avoid any situation they fear would
make them feel helpless if a panic attack occurs. When
people's lives become so restricted by the disorder,
as happens in about one-third of all people with panic
disorder, the condition is called agoraphobia. A tendency
toward panic disorder and agoraphobia runs in families.
Nevertheless, early treatment of panic disorder can
often stop the progression to agoraphobia.
Studies
have shown that proper treatment – a type of psychotherapy
called cognitive-behavioral therapy, medications, or
possibly a combination of the two – helps 70 to
90 percent of people with panic disorder. Significant
improvement is usually seen within 6 to 8 weeks.
Cognitive-behavioral
approaches teach patients how to view the panic situations
differently and demonstrate ways to reduce anxiety,
using breathing exercises or techniques to refocus attention,
for example. Another technique used in cognitive-behavioral
therapy, called exposure therapy, can often help alleviate
the phobias that may result from panic disorder. In
exposure therapy, people are very slowly exposed to
the fearful situation until they become desensitized
to it.
Some
people find the greatest relief from panic disorder
symptoms when they take certain prescription medications.
Such medications, like cognitive-behavioral therapy,
can help to prevent panic attacks or reduce their frequency
and severity. Two types of medications that have been
shown to be safe and effective in the treatment of panic
disorder are antidepressants and benzodiazepines.
Phobias
Phobias
occur in several forms. A specific phobia is a fear
of a particular object or situation. Social phobia (social
anxiety disorder) is a fear of being painfully embarrassed
in a social setting. And agoraphobia, which often accompanies
panic disorder, is a fear of being in any situation
that might provoke a panic attack, or from which escape
might be difficult if one occurred.
Specific
Phobias
"I'm
scared to death of flying, and I never do it anymore.
It's an awful feeling when that airplane door closes
and I feel trapped. My heart pounds and I sweat bullets.
If somebody starts talking to me, I get very stiff and
preoccupied. When the airplane starts to ascend, it
just reinforces that feeling that I can't get out. I
picture myself losing control, freaking out, climbing
the walls, but of course I never do. I'm not afraid
of crashing or hitting turbulence. It's just that feeling
of being trapped. Whenever I've thought about changing
jobs, I've had to think, 'Would I be under pressure
to fly?' These days I only go places where I can drive
or take a train. My friends always point out that I
couldn't get off a train traveling at high speeds either,
so why don't trains bother me? I just tell them it isn't
a rational fear."
Many
people experience specific phobias, intense, irrational
fears of certain things or situations – dogs, closed-in
places, heights, escalators, tunnels, highway driving,
water, flying, and injuries involving blood are a few
of the more common ones. Phobias aren't just extreme
fear; they are irrational fear. You may be able to ski
the world's tallest mountains with ease but panic going
above the 10th floor of an office building. Adults with
phobias realize their fears are irrational, but often
facing, or even thinking about facing, the feared object
or situation brings on a panic attack or severe anxiety.
Specific
phobias strike more than 1 in 10 people. No one knows
just what causes them, though they seem to run in families
and are a little more prevalent in women. Phobias usually
first appear in adolescence or adulthood. They start
suddenly and tend to be more persistent than childhood
phobias; only about 20 percent of adult phobias vanish
on their own. When children have specific phobias –
for example, a fear of animals – those fears usually
disappear over time, though they may continue into adulthood.
No one knows why they hang on in some people and disappear
in others.
If
the object of the fear is easy to avoid, people with
phobias may not feel the need to seek treatment. Sometimes,
though, they may make important career or personal decisions
to avoid a phobic situation.
When
phobias interfere with a person's life, treatment can
help. Successful treatment usually involves a kind of
cognitive-behavioral therapy called desensitization
or exposure therapy, in which patients are gradually
exposed to what frightens them until the fear begins
to fade. Three-fourths of patients benefit significantly
from this type of treatment. Relaxation and breathing
exercises also help reduce anxiety symptoms.
There
is currently no proven drug treatment for specific phobias,
but sometimes certain medications may be prescribed
to help reduce anxiety symptoms before someone faces
a phobic situation.
Social
Phobia
"I
couldn't go on dates or to parties. For a while, I couldn't
even go to class. My sophomore year of college I had
to come home for a semester."
"My
fear would happen in any social situation. I would be
anxious before I even left the house, and it would escalate
as I got closer to class, a party, or whatever. I would
feel sick to my stomach – it almost felt like I
had the flu. My heart would pound, my palms would get
sweaty, and I would get this feeling of being removed
from myself and from everybody else."
"When
I would walk into a room full of people, I'd turn red
and it would feel like everybody's eyes were on me.
I was too embarrassed to stand off in a corner by myself,
but I couldn't think of anything to say to anybody.
I felt so clumsy, I couldn't wait to get out."
Social
phobia is an intense fear of becoming humiliated in
social situations, specifically of embarrassing yourself
in front of other people. It often runs in families
and may be accompanied by depression or alcoholism.
Social phobia often begins around early adolescence
or even younger.
If
you suffer from social phobia, you tend to think that
other people are very competent in public and that you
are not. Small mistakes you make may seem to you much
more exaggerated than they really are. Blushing itself
may seem painfully embarrassing, and you feel as though
all eyes are focused on you. You may be afraid of being
with people other than those closest to you. Or your
fear may be more specific, such as feeling anxious about
giving a speech, talking to a boss or other authority
figure, or dating. The most common social phobia is
a fear of public speaking. Sometimes social phobia involves
a general fear of social situations such as parties.
More rarely it may involve a fear of using a public
restroom, eating out, talking on the phone, or writing
in the presence of other people, such as when signing
a check.
Although
this disorder is often thought of as shyness, the two
are not the same. Shy people can be very uneasy around
others, but they don't experience the extreme anxiety
in anticipating a social situation, and they don't necessarily
avoid circumstances that make them feel self-conscious.
In contrast, people with social phobia aren't necessarily
shy at all. They can be completely at ease with people
most of the time, but particular situations, such as
walking down an aisle in public or making a speech,
can give them intense anxiety. Social phobia disrupts
normal life, interfering with career or social relationships.
For example, a worker can turn down a job promotion
because he can't give public presentations. The dread
of a social event can begin weeks in advance, and symptoms
can be quite debilitating.
People
with social phobia are aware that their feelings are
irrational. Still, they experience a great deal of dread
before facing the feared situation, and they may go
out of their way to avoid it. Even if they manage to
confront what they fear, they usually feel very anxious
beforehand and are intensely uncomfortable throughout.
Afterward, the unpleasant feelings may linger, as they
worry about how they may have been judged or what others
may have thought or observed about them.
About
80 percent of people who suffer from social phobia find
relief from their symptoms when treated with cognitive-behavioral
therapy or medications or a combination of the two.
Therapy may involve learning to view social events differently;
being exposed to a seemingly threatening social situation
in such a way that it becomes easier to face; and learning
anxiety-reducing techniques, social skills, and relaxation
techniques.
The
medications that have proven effective include antidepressants
called MAO inhibitors. People with a specific form of
social phobia called performance phobia have been helped
by drugs called beta-blockers. For example, musicians
or others with this anxiety may be prescribed a beta-blocker
for use on the day of a performance.
Obsessive-Compulsive
Disorder
"I
couldn't do anything without rituals. They transcended
every aspect of my life. Counting was big for me. When
I set my alarm at night, I had to set it to a number
that wouldn't add up to a "bad" number. If
my sister was 33 and I was 24, I couldn't leave the
TV on Channel 33 or 24. I would wash my hair three times
as opposed to once because three was a good luck number
and one wasn't. It took me longer to read because I'd
count the lines in a paragraph. If I was writing a term
paper, I couldn't have a certain number of words on
a line if it added up to a bad number. I was always
worried that if I didn't do something, my parents were
going to die. Or I would worry about harming my parents,
which was completely irrational. I couldn't wear anything
that said Boston because my parents were from Boston.
I couldn't write the word 'death' because I was worried
that something bad would happen."
"Getting
dressed in the morning was tough because I had a routine,
and if I deviated from that routine, I'd have to get
dressed again. I knew the rituals didn't make sense,
but I couldn't seem to overcome them until I had therapy."
Obsessive-compulsive
disorder is characterized by anxious thoughts or rituals
you feel you can't control. If you have OCD, as it's
called, you may be plagued by persistent, unwelcome
thoughts or images, or by the urgent need to engage
in certain rituals.
You
may be obsessed with germs or dirt, so you wash your
hands over and over. You may be filled with doubt and
feel the need to check things repeatedly. You might
be preoccupied by thoughts of violence and fear that
you will harm people close to you. You may spend long
periods of time touching things or counting; you may
be preoccupied by order or symmetry; you may have persistent
thoughts of performing sexual acts that are repugnant
to you; or you may be troubled by thoughts that are
against your religious beliefs.
The
disturbing thoughts or images are called obsessions,
and the rituals that are performed to try to prevent
or dispel them are called compulsions. There is no pleasure
in carrying out the rituals you are drawn to, only temporary
relief from the discomfort caused by the obsession.
A
lot of healthy people can identify with having some
of the symptoms of OCD, such as checking the stove several
times before leaving the house. But the disorder is
diagnosed only when such activities consume at least
an hour a day, are very distressing, and interfere with
daily life.
Most
adults with this condition recognize that what they're
doing is senseless, but they can't stop it. Some people,
though, particularly children with OCD, may not realize
that their behavior is out of the ordinary.
OCD
strikes men and women in approximately equal numbers
and afflicts roughly 1 in 50 people. It can appear in
childhood, adolescence, or adulthood, but on the average
it first shows up in the teens or early adulthood. A
third of adults with OCD experienced their first symptoms
as children. The course of the disease is variable –
symptoms may come and go, they may ease over time, or
they can grow progressively worse. Evidence suggests
that OCD might run in families.
Depression
or other anxiety disorders may accompany OCD. And some
people with OCD have eating disorders. In addition,
they may avoid situations in which they might have to
confront their obsessions. Or they may try unsuccessfully
to use alcohol or drugs to calm themselves. If OCD grows
severe enough, it can keep someone from holding down
a job or from carrying out normal responsibilities at
home, but more often it doesn't develop to those extremes.
Research
by NIMH-funded scientists and other investigators has
led to the development of medications and behavioral
treatments that can benefit people with OCD. A combination
of the two treatments is often helpful for most patients.
Some individuals respond best to one therapy, some to
another. Two medications that have been found effective
in treating OCD are clomipramine and fluoxetine. A number
of others are showing promise, however, and may soon
be available.
Behavioral
therapy, specifically a type called exposure and response
prevention, has also proven useful for treating OCD.
It involves exposing the person to whatever triggers
the problem and then helping him or her forego the usual
ritual – for instance, having the patient touch
something dirty and then not wash his hands. This therapy
is often successful in patients who complete a behavioral
therapy program, though results have been less favorable
in some people who have both OCD and depression.
Post-Traumatic
Stress Disorder
"I
was raped when I was 25 years old. For a long time,
I spoke about the rape on an intellectual level, as
though it was something that happened to someone else.
I was very aware that it had happened to me, but there
just was no feeling. I kind of skidded along for a while."
"I
started having flashbacks. They kind of came over me
like a splash of water. I would be terrified. Suddenly
I was reliving the rape. Every instant was startling.
I felt like my entire head was moving a bit, shaking,
but that wasn't so at all. I would get very flushed
or a very dry mouth and my breathing changed. I was
held in suspension. I wasn't aware of the cushion on
the chair that I was sitting in or that my arm was touching
a piece of furniture. I was in a bubble, just kind of
floating. And it was scary. Having a flashback can wring
you out. You're really shaken."
"The
rape happened the week before Christmas, and I feel
like a werewolf around the anniversary date. I can't
believe the transformation into anxiety and fear."
Post-traumatic
stress disorder (PTSD) is a debilitating condition that
follows a terrifying event. Often, people with PTSD
have persistent frightening thoughts and memories of
their ordeal and feel emotionally numb, especially with
people they were once close to. PTSD, once referred
to as shell shock or battle fatigue, was first brought
to public attention by war veterans, but it can result
from any number of traumatic incidents. These include
kidnapping, serious accidents such as car or train wrecks,
natural disasters such as floods or earthquakes, violent
attacks such as a mugging, rape, or torture, or being
held captive. The event that triggers it may be something
that threatened the person's life or the life of someone
close to him or her. Or it could be something witnessed,
such as mass destruction after a plane crash.
Whatever
the source of the problem, some people with PTSD repeatedly
relive the trauma in the form of nightmares and disturbing
recollections during the day. They may also experience
sleep problems, depression, feeling detached or numb,
or being easily startled. They may lose interest in
things they used to enjoy and have trouble feeling affectionate.
They may feel irritable, more aggressive than before,
or even violent. Seeing things that remind them of the
incident may be very distressing, which could lead them
to avoid certain places or situations that bring back
those memories. Anniversaries of the event are often
very difficult.
PTSD
can occur at any age, including childhood. The disorder
can be accompanied by depression, substance abuse, or
anxiety. Symptoms may be mild or severe – people
may become easily irritated or have violent outbursts.
In severe cases they may have trouble working or socializing.
In general, the symptoms seem to be worse if the event
that triggered them was initiated by a person –
such as a rape, as opposed to a flood.
Ordinary
events can serve as reminders of the trauma and trigger
flashbacks or intrusive images. A flashback may make
the person lose touch with reality and reenact the event
for a period of seconds or hours or, very rarely, days.
A person having a flashback, which can come in the form
of images, sounds, smells, or feelings, usually believes
that the traumatic event is happening all over again.
Not
every traumatized person gets full-blown PTSD, or experiences
PTSD at all. PTSD is diagnosed only if the symptoms
last more than a month. In those who do have PTSD, symptoms
usually begin within 3 months of the trauma, and the
course of the illness varies. Some people recover within
6 months, others have symptoms that last much longer.
In some cases, the condition may be chronic. Occasionally,
the illness doesn't show up until years after the traumatic
event.
Antidepressants
and anxiety-reducing medications can ease the symptoms
of depression and sleep problems, and psychotherapy,
including cognitive-behavioral therapy, is an integral
part of treatment. Being exposed to a reminder of the
trauma as part of therapy – such as returning to
the scene of a rape – sometimes helps. And, support
from family and friends can help speed recovery.
Treatment
for Anxiety Disorders
Many
people with anxiety disorders can be helped with treatment.
Therapy for anxiety disorders often involves medication
or specific forms of psychotherapy.
Medications,
although not cures, can be very effective at relieving
anxiety symptoms. Today, thanks to research by scientists
at NIMH and other research institutions, there are more
medications available than ever before to treat anxiety
disorders. So if one drug is not successful, there are
usually others to try. In addition, new medications
to treat anxiety symptoms are under development.
For
most of the medications that are prescribed to treat
aniety disorders, the doctor usually starts the patient
on a low dose and gradually increases it to the full
dose. Every medication has side effects, but they usually
become tolerated or diminish with time. If side effects
become a problem, the doctor may advise the patient
to stop taking the medication and to wait a week –
or longer for certain drugs – before trying another
one. When treatment is near an end, the doctor will
taper the dosage gradually.
Research
has also shown that behavioral therapy and cognitive-behavioral
therapy can be effective for treating several of the
anxiety disorders.
Behavioral
therapy focuses on changing specific actions and uses
several techniques to decrease or stop unwanted behavior.
For example, one technique trains patients in diaphragmatic
breathing, a special breathing exercise involving slow,
deep breaths to reduce anxiety. This is necessary because
people who are anxious often hyperventilate, taking
rapid shallow breaths that can trigger rapid heartbeat,
lightheadedness, and other symptoms. Another technique
– exposure therapy – gradually exposes patients
to what frightens them and helps them cope with their
fears.
Like
behavioral therapy, cognitive-behavioral therapy teaches
patients to react differently to the situations and
bodily sensations that trigger panic attacks and other
anxiety symptoms. However, patients also learn to understand
how their thinking patterns contribute to their symptoms
and how to change their thoughts so that symptoms are
less likely to occur. This awareness of thinking patterns
is combined with exposure and other behavioral techniques
to help people confront their feared situations. For
example, someone who becomes lightheaded during a panic
attack and fears he is going to die can be helped with
the following approach used in cognitive-behavioral
therapy. The therapist asks him to spin in a circle
until he becomes dizzy. When he becomes alarmed and
starts thinking, "I'm going to die," he learns
to replace that thought with a more appropriate one,
such as "It's just a little dizziness – I
can handle it."
How
to Get Help for Anxiety Disorders
If
you, or someone you know, has symptoms of anxiety, a
visit to the family physician is usually the best place
to start. A physician can help you determine if the
symptoms are due to an anxiety disorder, some other
medical condition, or both. Most often, the next step
to getting treatment for an anxiety disorder is referral
to a mental health professional.
Among
the professionals who can help are psychiatrists, psychologists,
social workers, and counselors. However, it's best to
look for a professional who has specialized training
in cognitive-behavioral or behavioral therapy and who
is open to the use of medications, should they be needed.
Psychologists,
social workers, and counselors sometimes work closely
with a psychiatrist or other physician who will prescribe
medications when they are required. For some people,
group therapy or self-help groups are a helpful part
of treatment. Many people do best with a combination
of these therapies.
When
you're looking for a health care professional, it's
important to inquire about what kinds of therapy he
or she generally uses or whether medications are available.
It's important that you feel comfortable with the therapy.
If this is not the case, seek help elsewhere. However,
if you've been taking medication, it's important not
to quit certain drugs abruptly, but to taper them off
under the supervision of your physician. Be sure to
ask your physician about how to stop a medication.
Remember,
though, that when you find a health care professional
you're satisfied with, the two of you are working as
a team. Together you will be able to develop a plan
to treat your anxiety disorder that may involve medications,
behavioral therapy, or cognitive-behavioral therapy,
as appropriate. Treatments for anxiety disorders, however,
may not start working instantly. Your doctor or therapist
may ask you to follow a specific treatment plan for
several weeks to determine whether it's working.
NIMH
continues its search for new and better treatments for
people with anxiety disorders. The Institute supports
a sizeable and multifaceted research program on anxiety
disorders – their causes, diagnosis, treatment,
and prevention. This research involves studies of anxiety
disorders in human subjects and investigations of the
biological basis for anxiety and related phenomena in
animals. It is part of a massive effort to overcome
the major mental disorders, an effort that is taking
place during the 1990s, which Congress has designated
the Decade of the Brain.
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