ANXIETY

DOM I N IQUE E . ROE-SEPOWI T Z , LAURA E . BEDARD, AND BRUCE A . T HYER

Anxiety disorders are the most common, frequently occurring, so-called mental disorders in the United States (we say "so-called" because there are compelling reasons to doubt the notion that these conditions have their etiology in the "mind" of individuals). Differing from everyday stress and anxiousness caused by stimuli such as examinations, new jobs, and morning traffic, anxiety disorders are pervasive and chronic and may need professional care to alleviate or cure them. Over 19 million Americans between the ages of 18 and 54 are estimated to meet the formal diagnostic criteria for one or more anxiety disorders (National Institute of Mental Health [NIMH], 1999). Anxiety disorders can be the result of life stressors and events, learning, parental upbringing, illness-induced stress, genetic endowment and other biological conditions, and the inability to cope with and manage all of those factors at once. Mental health problems such as anxiety present particular problems during adulthood, including contributing to high rates of suicide, relationship problems, and difficulty functioning in society. Some specific events during adulthood (having children, divorcing, and expectations about success) can contribute to the development of an anxiety disorder.

Some anxiety is helpful, keeping persons alert and aware of their environment; too much anxiety, however, fatigues a person and can lead to diminished functioning. Anxiety disorders are linked by extreme or pathological anxiousness as the principal disturbance. The term anxiety disorder is formally given to pathological disturbances of affect, thinking, behavior, and physiological activity (U.S. Surgeon General, 1999). This subsumes emotional responses such as intense fear and feelings of dread and physical symptoms of shortness of breath, cold hands and feet, perspiration, lightheadedness or dizziness, rapid heart rate, trembling, restlessness, and muscle tension (U.S. Surgeon General, 1999). Anxiety disorders are characterized by an excessive or inappropriate state of fear, apprehension, and uncertainty (NIMH, 1999).


TYPES OF ANXIETY DISORDERS

There are several specific types of anxiety disorders, including the following.

Phobias

The underlying element in all phobias is an irrational fear of something. They can range in intensity from mild to traumatic, but "in all cases there is a sense of predictability which accompanies them" (Clark & Wardman, 1985, p. 13). The following are general definitions of several common phobias.

Specific Phobia

Formerly known as "simple phobia," specific phobia is persistent fear of an object or situation. According to the Diagnostic and Statistical Manual of Mental Disorders text revision (DSM; American Psychological Association, 2000), there are five subtypes of specific phobia: animal type (generally with childhood onset; examples include fear of snakes, dogs, or insects), natural environment type (fear of storms, heights, weather), blood-injection injury type (fear cued by seeing blood), situational type (fear cued by a situation such as crossing a bridge, driving, being in enclosed places), and other (e.g., fear of clowns, claustrophobia, fear of choking). Exposure to the stimulus causes intense fear and stimulates avoidance behavior by the individual. The fears are excessive and unreasonable. Most specific phobias begin during childhood and eventually disappear. They are more common in women than in men.

Social Phobia

Also called "social anxiety disorder," social phobia is diagnosed when a person's shyness and social avoidance becomes so severe and intense that it causes impairment or dysfunction. The anxiety-evoking stimulus involves being observed, judged, or evaluated by others. Social phobia is one of the most common anxiety disorders and can become worse over time if not treated (Thyer, 2002; Thyer, Tomlin, Curtis, Cameron, & Nesse, 1985). Social phobia is defined by the DSM as "marked or persistent fear of social or performance situations in which embarrassment may occur" (American Psychiatric Association, 2000, p. 450). Situations that are often feared by people with social phobia are speaking in public, participating in sports, being in public places, meeting new people, talking to an authority figure, using public lavatories when others are present, and musical or other performances. Clinical presentations may be different across cultures. By some criteria, social phobia is the third most prevalent mental health care problem in the world.

Agoraphobia

The word agoraphobia literally translates as " fear of the marketplace" (Clark & Wardman, 1985, p. 8) and refers to a generalized fear of being in public places. More specifically, agoraphobia is "anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms" (American Psychiatric Association, 2000, p. 432). This anxiety usually leads to the individual avoiding situations in which the anxiety may arise. In severe cases, individuals are unable to leave their comfort zone and often self-isolate to the point of being housebound.

General Anxiety Disorder

This disorder is characterized by excessive anxiety or worry accompanied by at least three of the following: restlessness, fatigue, lack of concentration, muscle tension, irritability, and lack of sleep. General Anxiety Disorder can manifest in physical symptoms such as trembling, twitching, muscle aches, and soreness as well as diarrhea and vomiting. The intensity and worry individuals report is grossly out of proportion to the real risk. This disorder frequently occurs with mood disorders and other anxiety disorders and is more common in women than in men.

Panic Disorder

Panic Disorder is characterized by panic attacks, which are described as a "rush of fear or discomfort that reaches a peak in less than 10 minutes" (Antony & Swinson, 2000, p. 12). These attacks are accompanied by physical symptoms such as a racing heart, shortness of breath, sweating, shaking, chest pain, faintness, and hot flashes or chills. Panic attacks often occur in the absence of any specific stimuli but can be brought on by stressful events such as an exam or a public speaking event. According to the DSM (American Psychiatric Association, 2000), there are three subtypes of Panic Disorder: unexpected (occur without warning or a precipitating event), situationally bound (occur in a particular situation, e.g., with phobia exposure), and situationally predisposed (these fall somewhere in between the two previous). Panic attacks are often disabling. Panic Disorder is estimated to impact more than 4% of Americans (Datilio, 2001).

Obsessive Compulsive Disorder

The DSM defines Obsessive Compulsive Disorder (OCD) as "recurrent obsessions or compulsions that are severe enough to be time consuming (more than 1 hour a day) or cause marked distress or significant impairment" (American Psychiatric Association, 2000, p. 458). OCD usually presents with both obsessive thoughts and compulsive behaviors, although individuals may suffer from only one. The obsessions are characterized by persistent thoughts, images, or impulses that cause marked anxiety or stress; for example, the thought of germs contaminating one's hands, ruminating over whether one locked the door, or the urge to blurt out an obscenity. The compulsive behaviors are often associated with the obsessions: with the thought of germs comes excessive hand washing, even to the point where the skin is extremely chafed. Adults with OCD usually realize that these actions are inappropriate, unreasonable, and excessive. If they do not come to this realization, the illness is referred to as OCD with poor insight.

Posttraumatic Stress Disorder

In Posttraumatic Stress Disorder (PTSD), a person who has experienced a traumatic situation that involved actual or threatened death or serious bodily harm responds with trauma-related symptoms of intense fear, helplessness, or horror. Events can include, but are not limited to, crime victimization, wartime events, or serious accident. Symptoms can include distressing dreams about the event, feeling as if the event is recurring, stress surrounding the anniversary of the event, flashbacks, or avoiding activities associated with the event. In addition, the individual may have difficulty concentrating, may have insomnia, may display outbursts of anger, may be unable to recall the traumatic event, and may display a lack of interest in activities. PTSD is common among victims of rape and personal assault and those who serve in active combat. Sometimes the victim is unable to make the connection between the traumatic event and current struggles.


PREVENTION

There has been much research on the diagnosis and treatment of adult anxiety disorders but little attention paid to prevention. Anxiety disorders can be prevented provided the person has access to treatment or prevention information in the early stages of the disorder (Leighton, 1987). Delay in treatment and a lack of information about anxiety disorders and management contribute to the development of a diagnosable anxiety disorder.

The primary problem with attempting to prevent anxiety disorders is that individuals often try to camouflage their disorder instead of getting treatment. They may hide their symptoms from friends, family members, and coworkers, leading to a delay in professional treatment and intervention for perhaps many years, or until they are so uncomfortable and the symptoms so overwhelming that they are functionally impaired (Craske & Zucker, 2001).

Anxiety prevention programs have slowly grown in numbers, but few have been empirically supported. Three types of prevention programs are discussed in this chapter: universal, selective, and targeted. Programs aimed toward preventing the entire population or a community from feeling stressed or anxious about life events are monumental undertakings. This type of program is called a universal preventive intervention. Selective interventions are aimed at a population known to be at risk for anxiety problems or at higher risk than the average person, such as adults who have been exposed to violence at home or in the community. Preventive interventions aimed at adults who are already showing signs and symptoms of anxiety disorders are called targeted.


TRENDS AND INCIDENCE

The cost of anxiety disorders to the United States is more than $42 billion a year, with more than $22 billion attributed to repeat medical care costs in a search for relief from symptoms that look like physical illness (Greenberg, Sisitsky, & Kessler, 1999). People with anxiety disorders are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders. About one in seven adults in the United States and Britain are affected by anxiety disorders each year (Brown, 2003; see Table 2.1 on page 18).

Catherine N. Dulmus, Lisa A. Rapp-Paglicci. Handbook of Preventive Interventions for Adults (2005).

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