Anxiety

ANXIETY

Anxiety is an unpleasant emotion characterized by a feeling of vague, unspecified harm. Like FEAR, it can cause a state of physical disturbance; unlike fear, it is characterized by the absence of an apparent cause, the circumstance that precipitates anxiety is hidden and unknown to the person. When the cause for anxiety becomes known but the feeling of apprehension remains, it is called worry.

Anxiety has many symptoms, most of which masquerade as genuine physical ailments.  Included are rapid or pounding heartbeat, difficult breathing or breathlessness, tremulousness, sweating, dry mouth, tightness in the chest, sweaty palms, dizziness, weakness, nausea, diarrhea, cramps, insomnia, fatigue, headache, loss of appetite, and sexual disturbances.  In addition to the uncomfortable bodily sensations associated with fear, anxiety results in a narrowing of one’s time perspective so that only the present matters;  it also results in an inability to attend to more than one task at a time or to organize thoughts and plans effectively.  Anxiety lowers one’s ability to perform most tasks.  Low levels of anxiety may temporarily increase a person’s ability to do a simple task, due to the greater vigilance and narrowing of one’s ATTENTION associated with anxiety, but as anxiety increases, behavior becomes more disorganized and ineffective.

PSYCHOANALYTIC THEORY

Two types of anxiety are recognized in psychoanalysis.  The first type, traumatic anxiety, results from over stimulation.  Events happen faster than the mind can comprehend them;  this produces a feeling of crisis.  Sigmund FREUD believed that this feeling has a physical basis in the capacity of the nervous system and that birth throws every child into a state of traumatic anxiety.  In his view, this birth trauma becomes the model for later episodes of anxiety.

The second type of anxiety in psychoanalysis, signal anxiety, is believed to arise from a person’s need to guard against the disorganization of traumatic anxiety.  The EGO appraises its own ability to cope with both external demands and the push of internal drives and wishes.  When normal methods of coping with these pressures threaten to fail, the ego responds with anxiety, which then mobilizes the person to take new action. The small-scale discomfort of signal anxiety helps to avoid a larger, more devastating experience.

LEARNING THEORY

In LEARNING THEORY, anxiety is seen both as a response to learned cues and as a drive, or motivator, of behavior.  Most learning theorists maintain that anxiety is derived from reaction to PAIN.  Anxiety can thus be reduced by removing or avoiding the source or sources of the situations that have produced pain.  Avoidance may become firmly established and lead to constricted or bizarre behavior.  A better way to reduce anxiety is to pair a strong, positive reinforcer such as food with the frightening situation so that the stimulus that formerly elicited anxious responses becomes associated with positive feelings.

COGNITIVE THEORY

In the control of anxiety, psychologists have recently focused on the role of cognition as the origin of anxiety.  Cognitive theories emphasize the process of appraisal and the often unnoticed internal dialogue that amplifies emotional response.  Experiments have shown that the interpretation of a situation determines whether a person feels anxiety or some other emotion.  Learning to substitute benign reappraisals for unrealistically negative “self-talk” reduces anxiety.

PHYSIOLOGICAL THEORY

Evidence exists that some persons may be biochemically vulnerable to an extreme form of anxiety known as “panic attacks.” Some medications relieve the panic, leading to the hope that anxiety can be understood physiologically, but the metabolic pathways are unknown and may be quite complex.  A combination of medication and therapies, including relaxation training, provides the best treatment for panic attacks.

SYMPTOMS OF ANXIETY DISORDERS

Anxiety is a normal part of life.  However, when anxiety becomes frequent and excessive it may indicate the presence of a clinically diagnosable anxiety disorder.

Those experiencing any of these symptoms may have an anxiety disorder:

• Panic or anxiety attacks
• Persistent senseless disturbing thoughts, excessive worrying
• Phobias or fears of common objects or situations
• Restlessness, feeling tense, keyed up
• Sleep problems
• Unexplained heart palpitations, stomach problems
• Feelings of unreality
• Concentration difficulties

Types of anxiety disorders include:

• Panic Disorder—characterized by panic attacks, sudden feelings of terror that strike repeatedly and without warning.  Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness or abdominal stress.
• Obsessive-Compulsive Disorder—Repeated, intrusive and unwanted thoughts that cause anxiety, often accompanied by ritualized behavior to relieve this anxiety.
• Phobias—Extreme and disabling fear of something that poses little or no danger and leads to avoidance of objects or situations.
• Specific Phobia—fear of specific objects or situations such as flying, heights and animals.
• Social Phobia—fear of being the focus of attention or scrutiny or of doing something that will be intensely humiliating.
• Post-Traumatic Stress Disorder—Persistent, frightening thoughts that occur after undergoing a frightening and traumatic event.
• Generalized Anxiety Disorder—Chronic or exaggerated worry and tension; almost always anticipating disaster even though nothing seems to provoke it.  Worrying is often accompanied by physical symptoms, like trembling, muscle tension, headache and nausea.

TREATMENT OF 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 anxiety 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.

BEHAVIORAL INTERVENTION APPROACHES FOR CHILDREN WITH EXCESSIVE ANXIETY

When anxiety is shown to an unusual or severe degree, assistance should be given to the child. Possible steps that might be taken, after adequate diagnosis, include the following:

1. Exploring the child’s feelings. Anxiety is considered unrecognized anger, and bringing the hostility to consciousness should tend to reduce inward tension.
2. Removing a threat that causes the child undue worry. For example, some pupils are concerned that older children will tease or physically harm them. In that case, the threat should be removed or the child relocated.
3. Modifying the expectations of the school and home if the student is unduly worried about homework, schoolwork, grades, or report cards.
4. Notifying police, social welfare, or other agencies if it is discovered that the student is worried about actual threatening situations.
5. Referring the child for professional help if he or she demonstrates nervousness to a debilitating degree.
6. Encouraging the pupil to experiment gradually with a situation that appears dangerous to him or her. for example, this approach may enable a child to speak before a group when he or she was previously unable to do so.
7. Reassuring the child that those around him or her do not harbor hostile feelings toward the child.
8. Refraining from attempts to force him or her to do tasks he or she is likely to fail at. Agree with the child, at the beginning, that he or she probably cannot succeed. This will tend to allay feelings of guilt and anxiety. Direct the child to a task that he or she can accomplish.
9. Sympathizing with the child’s uncomfortable feelings. Do not employ sarcasm or ridicule.
10. Reinforcing correct answers and behaviors quickly and positively.
11. Allowing the child to set his or her own goals.
12. 12. Pointing out to the parents that they probably should not tutor their child. This approach must be handled cautiously: many parents are as anxious as their children and may resist well-meant suggestions.

Bibliography:  Beck, A. T., Cognitive Therapy and the Emotional Disorders (1976);  Berger, J. G., ed., Antianxiety Agents (1986); 

Costello, Charles G., Anxiety and Depression (1976);  Dollard, John, and Miller, Neal, Personality and Psychotherapy (1950); 

Freud, Sigmund, The Problem of Anxiety (repr. 1966);  Gittelman, Rachel, ed., Anxiety Disorders of Childhood (1986);  Goodwin, D.  W., Anxiety (1986);  May, Rollo, The Meaning of Anxiety (1977); 

Spielberger, Charles, ed., Anxiety and Behavior (1966); 

Zuckerman, M., and Spielberger, Charles D., eds., Emotions and Anxiety (1976).