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.
This article gives brief explanations of panic disorder (which is sometimes accompanied by agoraphobia),obsessive-compulsive disorder, post- traumatic stress disorder, specific phobias, social phobias, and generalized anxiety disorder.
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.
The disturbing thoughts or images are called obsessions, and the rituals 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.
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.
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
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.
Phobias occur in several forms. A specific phobia is a fear of a particular object or situation. Social phobia 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.
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 (Social Anxiety Disorder)
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. Afterwards, 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.
Generalized Anxiety Disorder
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.
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 worried 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.