Anxiety disorders are disorders which generally create fear, worry, and a sympathetic nervous system response. There are five main types of anxiety disorders. They include:
1. Generalized Anxiety Disorder
2. Panic Disorder
3. Obsessive Compulsive Disorder
4. Post Traumatic Stress Disorder
5. Phobias

Explanations
Psychoanalytic: Anxiety disorders are the discharging of repressed impulses
Behavioral: Anxiety disorders are a product of fear conditioning, stimulus generalization, reinforcement, and observational learning
Biological: Evolutionary, genetic, and psychological influences

Generalized Anxiety Disorder (GAD)

[[#|Generalized anxiety disorder]] is characterized by persistent, excessive, and unrealistic worry about everyday things.

People with the disorder, which is also referred to as GAD, experience exaggerated worry and tension, often expecting the worst, even when there is no apparent reason for concern. They anticipate disaster and are overly concerned about money, health, family, work, or other issues. Sometimes just the thought of getting through the day produces anxiety. They don’t know how to stop the worry cycle and feel it is beyond their control, even though they usually realize that their anxiety is more intense than the situation warrants. The "worry cycle" which many GAD patients experience is when one worries about worrying, and with worrying comes unrealistic anxiety, it normally takes medication of some sort or therapy to break this cycle.

GAD affects 6.8 million adults, or 3.1% of the U.S. adult population, in any given year. In clinical samples the prevalence in males and females appears to be equal. Of GAD patients, 80% had at least one other anxiety disorder in their lifetime, and 7% had [[#|major depression]].

The disorder comes on gradually and can begin across the [[#|life cycle]], though the risk is highest between childhood and middle age. Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role.

When their anxiety level is mild, people with GAD can function socially and be gainfully employed. Although they may avoid some situations because they have the disorder, some people can have difficulty carrying out the simplest daily activities when their anxiety is severe.

People with [[#|generalized anxiety]] disorder (GAD) experience constant, chronic, and unsubstantiated worry, often about health, family, money, or work. This worrying goes on every day, possibly all day. It disrupts social activities and interferes with work, school, or family.
Physical symptoms of GAD include the following:

By DSM IV (To be diagnosed you must have 3 or more symptoms. In children, only one symptom is required)
  • muscle tension
  • easily fatigued
  • restlessness or feeling keyed up or on edge
  • trouble falling or staying asleep
  • irritability
  • edginess

Other Symptoms
  • gastrointestinal discomfort or diarrhea
  • Nausea
  • Trembling
  • Sweating
  • Dizziness
  • Problems sleeping
  • Shortness of breath


Case Study: "I Can't Stop My Head": The Case of the Persistent Worrier (GAD)

Psychiatric and Medical History

Nancy L., a 45-year-old married lawyer, presented with exacerbation of her chronic generalized anxiety and recurrent [[#|depressive symptoms]] in January 2005.
Nancy had a history of anxiety dating back "as far as I can remember." She was an anxious young girl with separation anxiety and shyness that manifested in elementary school. As she grew up, she experienced ongoing anxieties about the health of her parents (worrying that her parents would die, even though they were in good health) and her school performance (though she was a good student). She remembers marked fears, including fears of the dark and thunder, most of which she "outgrew" except for a persistent fear of insects, particularly spiders.
Her anxiety became more prominent and persistent after she left home at age 18 and entered college. She sought care at the university health service and received a prescription for diazepam that she used over the next 4 years on an as-needed basis during periods of increased anxiety such as examinations; she also met episodically with a therapist at the counseling center. In the spring of her freshman year, she experienced her first [[#|major depressive episode]] following a break-up with a boyfriend. She was prescribed imipramine, which she took for a couple of months but then discontinued because of intolerable side effects (dry mouth and [[#|lightheadedness]]). The depression gradually resolved over the next 6 months.
Nancy continued to be plagued by persistent feelings of anxiety and worry associated with insomnia, irritability, tension, and fatigue. Over the years, her friends and family chided her for "worrying too much," and she reported difficulty controlling her anxiety over her financial situation, job security, and her children's safety, despite evidence that none of these were problematic. Her husband reported that he found her persistent anxiety and ongoing need for reassurance "exhausting" and that he noticed himself withdrawing from her, which led to significant tension between them. The high quality of her work at the law firm was recognized and she was well-compensated financially, yet she continued to worry about her performance and was, in fact, passed over for promotion to team leader because, as one of her annual reviews stated, her "constant anxiety makes everyone else too nervous." In addition, over the last 25 years, she has had 5 or 6 episodes of major depression lasting from 3 to 4 months to over a year. These episodes have sometimes, but not always, been triggered by situational stressors; one occurred during a postpartum period.
After college, she was treated intermittently with benzodiazepines at low doses (eg, diazepam 5-10 mg), which she took on an as-needed rather than daily basis when the anxiety worsened because of her concerns about addiction. As noted, she was briefly on imipramine during college but discontinued it because of side effects. About 10 years before the January 2005 examination, she was started on fluoxetine 20 mg/day by her primary care doctor. She discontinued it after a few days because it made her feel jittery and more anxious. She had been in supportive therapy on and off since college to help her deal with situational stressors.
Other relevant aspects of her medical and psychiatric history include the fact that her overall health had been generally good, although she had presented numerous times to her primary care physician with a variety of somatic complaints, including headaches, gastrointestinal disturbance, and muscular aches and pains with no clear etiology. She had repeated thyroid testing with normal results. Her mother had had a history of menopause in her early 40s and the patient noted that her menstrual cycles had become more irregular over the last couple of years, and her anxiety and irritability become notably worse premenstrually.
She smoked a pack of cigarettes a day and reported that having a cigarette would sometimes temporarily decrease her tension and anxiety. She attempted to quit smoking several times and noted that the increased anxiety and tension she experienced during these attempts contributed to her lack of success in these efforts. She typically had 1 or 2 glasses of wine at social occasions or on the weekends; she has no history of abuse or dependence on alcohol but did say that a glass of wine made her feel temporarily less anxious. She carefully monitored her intake because of worry that she would become an alcoholic. She smoked marijuana a few times in college but it made her feel dysphoric and more anxious, and she had not used it or other illicit drugs since that time.

Social and Family History

After finishing college, Nancy went to law school, where she met her husband. She reported being attracted to his sense of calm and stability. He reported that part of what drew him to her was the sense of how much she seemed to need and depend on him. They were married shortly after graduation and had 2 children over the next 5 years. After the birth of her second child, she developed a postpartum depression that lasted almost a year and for which she didn't seek treatment. She said that her youngest child "is just like I was -- she's afraid of her own shadow."
She grew up in a middle-class home, the second of 3 children. She reported that childhood was "generally happy," although she was troubled by anxiety starting early in life. There was no history of physical or sexual abuse. Both parents were still alive in January 2005, although they had significant medical conditions and she was worried about their health. She noted that her mother and father were both "nervous" people, and though never formally diagnosed and treated, her maternal grandmother had a history of depression.



Panic Disorder
Panic disorder is diagnosed in people who experience spontaneous seemingly out-of-the-blue panic attacks and are preoccupied with the fear of a recurring attack. Panic attacks occur unexpectedly, sometimes even during sleep. Drug usage and sometimes even alcohol consumption can bring out panic disorder in people who are pre-exposed genetically to panic-disorder.

Symptoms


A panic attack is defined as the abrupt onset of intense fear that reaches a peak within a few minutes and includes at least four of the following symptoms:
  • a feeling of imminent danger or doom
  • the need to escape
  • heart palpitations
  • sweating
  • trembling
  • shortness of breath or a smothering feeling
  • a feeling of choking
  • chest pain or discomfort
  • nausea or abdominal discomfort
  • dizziness or lightheadedness
  • a sense of things being unreal, depersonalization
  • a fear of losing control or "going crazy"
  • a fear of dying
  • tingling sensation
  • chills or heat flush
Since many of the symptoms of panic disorder mimic those of illnesses such as heart disease, thyroid problems, and breathing disorders, people with panic disorder often make many visits to emergency rooms or doctors' offices, convinced they have a life-threatening illness. It often takes months or years and a great deal of frustration before receiving the correct diagnosis.
Many people suffering from panic attacks don't know they have a real and treatable disorder.



Treatment:
Although medication can be useful, psychotherapy (especially behavioral and cognitive/behavioral approaches) have proved quite successful. The key to treatment is accepting the panic attacks as psychological rather than physical (once these causes have been ruled out by a physician), practicing relaxation exercises, and working through the underlying issues. As found in the DSM-IV

Post-Traumatic Stress Disorder:

Post-Traumatic Stress Disorder - A Case Study

by Mark Sichel, LCSW


"I was in the park talking with my friend and I had my dogs with me. I see Officer Breck and I feel worried because I've seen him harass people in the past, so I start to leave the park. Plus, I've had a long history of community activism, and I've had several verbal altercations with Officer Breck myself. As I'm leaving, Officer Breck is entering the park, and I say 'How are you?' He says, 'Better than you. I keep walking and he pushes me hard on the shoulder. I say, 'Is that legal?' I start to walk forward and he keeps pushing me back. He then says, 'I'm going to shoot your dogs, lady.'

"I became so frightened at that point that I peed in my pants. I was terror struck. I asked him please to stop. I told him I was pregnant and said I was sorry. He said he didn't care. I went into a panic when he reached for his walkie-talkie. I thought he was getting his gun because he keeps saying that he's going to shoot my dogs. He tries to handcuff me and I'm terrified that if I let the dogs go they'll bolt into the street and get hit by cars. When I resisted the handcuffs because of the danger to the dogs, he threw me on my stomach, stepped on my back, and handcuffed me. He then threw me into the police car and fortunately my friend had arrived and she took the dogs.

"I start to think I'm miscarrying because I didn't realize I had urinated in my pants and I thought I was bleeding profusely. My friend kept telling Breck to stop because I'm pregnant. I keep crying and saying I'm losing my baby. Suddenly there are four police cars and eight officers. They tell me they're going to tie my dogs to a pole on the street and Officer Breck keeps saying he's going to shoot the dogs. My friend has managed to reach my husband, Steve, who arrives in the park. When he gets there, Officer Breck says to him, 'I never laid a hand on her.' He then asks my husband if I've taken my medicines. He tells Breck that I'm pregnant, and not on medication. The police then gave me a ticket for disorderly conduct."

The narrator of the above story is a 34-year-old married woman with one child who we'll call Karen*. She has a history of provocative behavior, but has never been in trouble with the law. She's come to see me three weeks after this incident, complaining of overwhelming anxiety and fear. She feels hopeless and helpless, and is consumed with obsessive thoughts about what happened to her that day in the park three weeks ago.

"I have nightmares every night now. Last night, I dreamed that I was being shot, along with my dogs, executioner style. I was on my knees and facing away from the executioner with one dog on either side of me. The dogs were shot and then I turned around and saw Officer Breck and I woke up terror struck. I got no sleep for the rest of the night. I'm exhausted, scared, confused, and angry. I can't take care of my son, and I'm terribly worried about my pregnancy. Then I had another dream that I'm in the cop car and the cops are laughing at me. I'm peeing in my pants, thinking I've lost my baby and they're laughing."

This reliving and re-experiencing of the traumatic event is the central symptom of post traumatic stress disorder. Chronic and persistent dreams of the traumatic event, and difficulty sleeping are also core symptoms of this disorder.

Karen continued to tell me her ongoing difficulties as the session continued. "When I see a cop I get terrified. I start to feel like I'm in terrible danger, and my heart starts to beat rapidly, I sweat, shake, can't breathe. My stomach hurts and I'm nauseous a lot of the time. It's terrible because I'll be out with my son and I'll see a police car and my adrenaline starts pumping and I get a startled look on my face. I immediately go back to the house, and proceed to get sick in the bathroom."

Hypervigilance, exaggerated startle response, and physiological symptoms such as palpitations, abdominal distress, sweating, breathing difficulties, are all typical responses for people who are suffering a post-traumatic stress disorder.

As Karen continued her therapy with me, more symptoms of post-traumatic stress disorder continued to emerge. As she talked through the episode with Officer Breck and what happened to her that day, she slowly started to feel better.

The most helpful treatment for Post-Traumatic Stress Disorder (PTSD) is to talk about what happened during the event, and to share your feelings with another person. It's most helpful if this person is a trained and licensed therapist, but it's useful to discuss it with others as well.

As is the case with many emotional problems, the course of treatment is never a straight up hill progress, for there are often regressions that can follow progress. If you are experiencing PTSD, don't get frightened if your progress is sometimes slowed down by a return of symptoms. This is normal and to be expected, and will go away eventually if you continue to work on your problem.

Karen came in one day after ten weeks of therapy, and told me that she had stayed in bed all weekend, unable to mobilize herself and feeling dissociated and detached from her own experience. She was fortunate to have had her husband at home to take care of their son, but found it distressing that she had no interest in any of her usual activities. Feelings of detachment and estrangement and loss of interest in significant activities are also symptoms of PTSD. I reassured Karen that a regression or backslide in progress was not unusual, and asked her if something had happened that could have caused this.

"Oh yes, for sure something happened," she said. "I saw Officer Breck riding on bicycle patrol and yelling at a woman with a dog. I was terror struck. The whole horrible event with him came back to me. I instantly lost control and peed in my pants. My heart was pounding, I was shaking and couldn't breathe and then vomited and had diarrhea all weekend. I just lay in the bed the whole weekend, completely numb and frightened. I guess I couldn't even deal with this until I saw you in a session."

Karen's treatment progressed for another ten weeks, with progress followed by back-sliding. At one point she had a particularly bad day, and realized it was because she had run into Officer Breck in the supermarket. He was in civilian clothes, but as soon as she saw him, she freaked out. She continued to feel frightened of going out of her house, and most certainly avoided the park where the incident took place. Avoidance of activities, places or people that arouse recollection of the traumatic event is another central symptom of PTSD.


What is Post Traumatic Stress Disorder?

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 and can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe and 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 natural event such as 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.

Symptoms:

  • Experiences flashbacks, traumatic daydreams, or nightmares in which he or she relives that traumatic event again.
  • Irritability or outbursts of anger.
  • Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
  • Difficulty falling or staying asleep
  • Difficulty concentrating.

Links:
Anxiety Disorder Association of America
**Screening for Generalized Anxiety Disorder (GAD)**
http://www.youtube.com/watch?v=dRmBJhtys9g
http://www.youtube.com/watch?v=U6QuNjlHsHw&playnext=1&list=PL03017C6184B3FC87
http://www.medscape.org/viewarticle/527758_4