What is an anxiety disorder?

Anxiety is a normal emotion that people experience when facing uncertainty or danger. It is closely related to fear and nervousness. But fear is usually more specific than anxiety. I might be afraid to go to a party because I might meet so and so, while I might be anxious about going to the same party because I might not feel comfortable there. Nervousness is a physically unpleasant state in which someone feels tense or shaky, and experiences trembling, rapid heart beat and/or sweating. Anxiety can have an emotional component, a cognitive (thought) component of worry, and a physical component that is similar to nervousness. When the anxiety becomes severe and/or prolonged, the affected person may be suffering from an anxiety disorder.

There are a number of specific anxiety disorders. People with panic disorder experience recurrent, unexpected panic attacks. These attacks are characterized by the abrupt onset of extreme fear, accompanied by such symptoms as rapid heart beat, shortness of breath, trembling, shaking, the fear that one is about to die or lose emotional control, and a strong urge to flee. In people suffering from panic disorder, such panic attacks seem to come out of the blue, causing extreme fear of having another attack and great concern about one's health. Another complication of panic disorder is agoraphobia, in which people are afraid to travel far from home or go into confined places (trains, elevators, planes) for fear of having a panic attack and being unable to flee quickly or get help.

People with generalized anxiety disorder (GAD) do not experience a panic attack as their primary symptom. Rather, they chronically worry too much about a variety of things, and experience symptoms such as restlessness, agitation, or feeling keyed up, muscle tension, fatigue, irritability, and trouble with concentration and with sleep.

Social anxiety disorder is characterized by extreme fear and avoidance of social and/or performance situations. Some people have extreme discomfort when giving a speech, interviewing for a job, or performing in public, but are otherwise comfortable socially. When trying to perform, they get racing of the heart, sweating, trembling, blushing, and also mental confusion. These people are said to have nongeneralized social anxiety disorder. In contrast, individuals with generalized social anxiety disorder experience extreme discomfort in many social as well as performance situations. Those with generalized social anxiety disorder are uncomfortable dating, talking to bosses or colleagues, going to parties and even chatting informally with coworkers, in addition to their fear and avoidance of performance-type situations.

Anyone who saw Jack Nicholson's recent movie "As Good As It Gets" is familiar with obsessive compulsive disorder (OCD). Very particular fears such as of dirt, germs, contamination or danger keep intruding into one's mind. Certain behaviors or thoughts will calm the fears temporarily—extensive handwashing or bathing for obsessions about germs; repeated checking of doors, stoves, or other objects for uncertainty about doing things correctly; inability to throw out useless items in response to an excessive fear that something potentially useful may also be discarded.

Finally, there is post traumatic stress disorder (PTSD), a very troubling condition that may follow terrible emotional trauma. The trauma may be a single event—a mugging or rape, an auto accident in which someone close to you is killed or you are almost killed, or a more chronic exposure, such as military combat, political torture or childhood sexual or physical abuse.

Affected individuals are left with a triad of problems: they continue to recollect or reexperience the trauma much more frequently then they want to, they lose interest in former pursuits and experience emotional numbing, and they become exceedingly jumpy, nervous and hypervigilant.

Who gets an anxiety disorder?

Both your inherited nature or constitution and what you experience in life determine whether you will suffer an anxiety disorder. Your odds of developing panic disorder, GAD, social anxiety disorder, or OCD all seem to be greater if one of your parents or siblings has the condition. This suggests that some vulnerability is passed on in the genes, although it could also be modeled or taught in some way by affected relatives. Even PTSD appears to require some vulnerability in most cases, since not everyone who experiences most traumas develops PTSD (This may be less true for chronic severe exposures like prolonged political torture.)

We also know something about environmental triggers. Panic disorder often begins in a context of separation from loved ones—going off to college, for example, is a common precipitant. Hormonal instability also can be a trigger, and abnormal thyroid function is found in many newly diagnosed cases of panic disorder. Environmental stress may be a trigger for GAD—loss of a job and trouble finding another, chronic health concerns in oneself or a family member, and so on. Social anxiety disorder, especially the generalized type, seems to be associated with a shy, anxious temperament as a child, but also with parental overprotectiveness, so that socially timid individuals never learn to cope. OCD may sometimes be triggered by strep infections, similar to what is found for rheumatic fever. Certain brain infections or injuries can also bring on the disorder. Severe trauma is required for PTSD, but a prior trauma, another anxiety disorder, or even having a family member with an anxiety disorder predisposes one to developing PTSD.

Why do you get anxiety disorders and how?

Social anxiety disorder and GAD appear most gradually, and affected adults often show milder symptoms in childhood and adolescence. It may be that as social or general responsibilities increase with age, the disorders become more manifest. OCD can begin in childhood, especially in boys, or adolescence, more often in girls. Panic disorder usually comes later; late teens or early to mid 20s is a common age of onset. In PTSD, the age of onset is the most variable, since it is dependent on when a severe trauma is experienced.

We think that certain changes in brain chemistry and activity are associated with each anxiety disorder, although our knowledge about this is far from complete. Panic disorder seems associated with a lowered threshold for, or spontaneous firing of, certain alarm systems in the brain, ­like having a burglar alarm that goes off when the wind blows strongly, or even discharges randomly, instead of only when someone is breaking into the house. Abnormalities in the neurotransmitter chemical dopamine have been found in certain brain regions in people with generalized social anxiety disorder; interestingly, similar abnormalities have been found in individuals high in social avoidance or detachment. OCD has been associated with certain abnormalities of another brain neurotransmitter, serotonin, which is a "worry" chemical, and also with heightened activity of particular brain areas in the frontal lobes and basal ganglia.

Do you have an anxiety disorder?

There are several hallmarks of an anxiety disorder. One is extreme anxiety, fear or nervousness. This can be episodic, such as having panic attacks once a week, or chronic, such as having GAD symptoms on a daily basis. Trouble falling asleep or staying asleep is a common symptom of generalized anxiety disorder. Another marker of an anxiety disorder is a desire to avoid situations where you used to be comfortable, or where you need to go to function successfully. This phobic avoidance can involve the extreme reluctance to travel far from home (agoraphobia) that accompanies panic disorder; the avoidance of necessary or useful social or performance situations that accompanies social anxiety disorder; the avoidance of any possible contact with germs, dirt or contamination that is frequently seen in OCD; or avoiding any situation that brings back memories of a past traumatic incident, which is frequently seen in PTSD.

Certain other conditions may produce symptoms that look like an anxiety state. Depression may be associated with nervousness, sleeplessness and social avoidance. Medical conditions like hyperthyroidism can produce nervousness, trembling, sweating and rapid heart beat. Excessive use of caffeine or other stimulants, or withdrawal from tranquilizers or alcohol, can produce symptoms that mimic an anxiety disorder. This is why experienced physicians will check for these other conditions before diagnosing an anxiety disorder.

Can you alter the course of an anxiety disorder?

Certain things can help to lessen the symptoms of an anxiety disorder. Giving up caffeine and other stimulants, and moderating alcohol use, are all helpful. Avoidance of further traumatic experiences, to the extent possible, is also helpful in reducing the long-term impact of PTSD. Having successful experiences will help overcome phobic avoidance. For example, social anxiety can be lessened by success at work or in personal relationships.

What can you do to care for your anxiety disorder?

Our knowledge of how to treat anxiety disorders has progressed greatly over the past two decades. In general, both medications and specific forms of therapy are helpful. In terms of medication, one or more of the selective serotonin reuptake inhibitors (SSRIs) have been found helpful for panic disorder, social anxiety disorder and OCD, and their use is being studied in GAD and PTSD. Medications that inhibit the reuptake of both norepinephrine and serotonin (SNRI's) have been found useful for GAD and panic disorder . One or more benzodiazepine tranquilizers have also been found useful for panic disorder, social anxiety disorder and GAD. A number of these medications were first found useful for depression, but are now known to help anxiety disorders even if the affected persons are not depressed.

Particular cognitive and behavioral therapy approaches also help most anxiety disorders, either in conjunction with medication or alone. The techniques vary according to the specific anxiety disorder, but usually involve getting individuals to face their feared situations while providing them with cognitive (thinking) strategies for reducing their anxiety.

Education is the third leg of the therapeutic triad. The more an affected person knows about his or her condition, the easier it is to overcome. Patient support groups are very useful both at imparting information and encouraging people to persist in seeking professional help.

What are the complications of an anxiety disorder?

Anxiety disorders have a number of complications. The first is suffering and reduced functioning. In the extreme, this can lead to complete disability, in which an affected person can no longer go to school or hold a job. Depression is also a frequent complication, making the situation worse and heightening the risk for suicide. Substance abuse is also a frequent complication, particularly attempts at self-medication with sedatives or alcohol, and may require parallel treatment by a substance-abuse counselor or program.