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Anxiety

Anxiety

Theoretical positions

Human anxiety—empirical generalizations

Anxiety—an integrative point of view

Anxiety neurosis

BIBLIOGRAPHY

There is no single problem of anxiety. Different theorists and different experimental investigators have tackled various aspects of a broad complex of phenomena, all of them summarized under the unifying conceptual category of anxiety. Anxiety has variously been considered as a phenomenal state of the human organism, as a physiological syndrome, and as a theoretical construct invoked to account for defensive behavior, the avoidance of noxious stimuli, and neurotic symptoms.

Historical background. The role of anxiety in the study of personality has been peculiarly a child of the twentieth century. The eighteenth-century and nineteenth-century precursors of modern psychology were first of all concerned with the rational aspects of human personality development, and it was not until the work of Alexander Bain (1859) that motivational concepts became important in speculations about complex human behavior. Thus, with the exception of such precursors of modern existential philosophy and psychology as Kierkegaard (1844), historically there was little central concern with the problem of anxiety.

However, negative, aversive, and unpleasant emotions have been the concerns of modern thinkers. Anxiety has not only been considered as the negative emotion par excellence in the theoretical writings of psychological theorists; but, even apart from its prototypical status as a negative emotion, it became generally the central emotional concept of many theoretical treatments in psychology. Anxiety was emotion.

On the whole, anxiety has remained the child of the psychologist, the problem of the individual. While philosophers, anthropologists, and sociologists have at various times taken the psychologist’s notion of anxiety and speculated about its social and cultural antecedents, the major contributions in the area of anxiety have been those of psychologists.

The following schema briefly recapitulates the various theoretical and empirical concerns that have collectively come to be known as the problem of anxiety.

The three faces of anxiety. Three general rubrics describe various emphases within the problem of anxiety: antecedent, organismic-hypothetical, and consequent conditions. While this triad can be conceptually delimited, there are, as will be obvious, borderline problems that defy any simple categorization.

Antecedent conditions. In the first instance, there has been a continuing interest in the antecedent conditions that give rise to the anxiety phenomenon. Practically all workers in the field have, at one time or another, been concerned with the stimulus that elicits anxiety. What is it in the environment that gives rise to the experience of anxiety or to the behavior that is symptomatic of anxiety? With the notable exception of the existentialists and some psychoanalytic writers, considerations of these conditions have usually viewed anxiety as an acquired emotion, rarely found until the organism has gone through some learning experiences. As an acquired emotion, it is often distinguished from the fear aroused by a threatening or noxious event, and it is usually reserved for those learned conditions that signal or cue the impending occurrence of tissue injury or some other threat to the integrity of the organism.

Organismic conditions. The second set of conditions that is subsumed under the problem of anxiety is the hypothesized or observable state of the organism. While a theoretical purist can easily postulate the anxiety state as a hypothetical theoretical device with explanatory functions only, most notions about the phenomenon have, in addition, assumed some physiological or specifically autonomic arousal state. Those who have taken a specific position in this regard have usually assumed that the experience of anxiety is accompanied by some measurable level of sympathetic nervous system discharge. While there has been some speculation whether this discharge shows a specific pattern for the emotion of anxiety, generally it has been assumed that while the discharge may be specific to the individual it is likely not to be specific to the emotion. On the other hand, the autonomic processes involved have frequently been ignored, and, while some state of the organism has been postulated, its specific empirical referents have not necessarily been investigated. This position is particularly true of the concept of anxiety used by learning theorists in the United States. Even they, however, have at times spoken about specific proprioceptive (i.e., internal) cues associated with the anxiety state.

Consequent conditions. The consequent, experiential, or response aspects of anxiety have probably shown the widest variety of definition and emphasis. It can be assumed that the experience of anxiety falls into a general category of conditions, all of which occur consequent to some prior event or state of the organism; that is, some event must act upon receptors to be experienced. The subjective experience of anxiety is accessible only through the report of the human observer; as such, it is a behavioral, consequent event and falls into the same category as other behavioral and verbal consequences of some real or hypothetical anxiety state. One major group of anxiety theorists, the existentialists, has concerned itself primarily with these experiential correlates. In addition to what the anxious human being says about himself, the problem of anxiety deals with the effect of the various antecedent and intervening states on practically all aspects of his behavior. Apart from the effect of anxiety on neurotic or other pathological behavior, anxiety has been studied as it affects early learning, child rearing, adult acquisition of normal aversions and apprehensions, motor behavior, complex problem solving, and so forth (cf. Cofer & Appley 1964). Anxiety has also been defined in terms of expressive behavior, general level of activity, and a whole class of diagnostic behavioral and physiological symptoms.

While these three general classes of variables— antecedent, organismic, and consequent—provide a general overview of the extent of the problem of anxiety, they are, like most categories in the behavioral sciences, hardly mutually exclusive. Various conditions may at various times shift from an organismic to a consequent state, or even from a consequent to an antecedent, as, for example, when anxious behavior becomes the cue for further anxiety. Quite understandably, several writers on the problem have stressed the importance of different aspects of this triad. When the learning theorist is dealing with anxiety, he is dealing primarily with antecedent-consequent relations; when the existentialist speaks of anxiety, he is concerned primarily with the experience of anxiety and possibly with some organismic state, whereas he has relatively little concern with antecedent conditions of learning.

With these general considerations in mind, three major theoretical positions will be given a brief exposition, followed by a summary of known and stable empirical findings, a general unifying statement on the problem of anxiety, and an exposition of pathological anxiety.

Theoretical positions

Psychoanalytic theory

While much has been written about the development of, and changes in, the psychoanalytic concept of anxiety, the major position, even after several decades, remains Sigmund Freud’s own set of statements. Nothing attests better to the complexity of the problem of anxiety than Freud’s concern with an adequate theory of anxiety. In no other area did he change his point of view as dramatically as he did toward the origins and mechanisms of anxiety, in fact presenting two theories on the topic.

Freud’s early theory of anxiety, generally stated in 1917 (Freud 1916–1917), was relatively straightforward and part of the general energy system of psychoanalytic theory. Anxiety was defined as transformed libido. The transformation occurs as a result of repression, which distorts, displaces, or generally dams up the libido associated with instinctual impulses. This transformation-of-libido or “damming-up” theory of anxiety suggests that whenever the organism is prevented from carrying out an instinctually motivated act, whether through repression or through some prevention of gratification, anxiety will ensue. Such anxiety may, of course, then serve as a motive for a symptom that in turn functions to terminate or completely prevent the subsequent occurrence of anxiety. This theory was amended in 1926 when Freud published Inhibitions, Symptoms and Anxiety. The new position was restated in the New Introductory Lectures on Psychoanalysis in 1933 and in general remained his final statement on anxiety.

The second theory reversed the relationship between repression and anxiety. Although Freud tended to maintain the possibility of both kinds of relationships, the second theory added the possibility that repression occurs because of the experience of anxiety. To Freud, this was the more important possibility. In this context, anxiety becomes a signal from the ego. Whenever real or potential danger is detected by the ego, this perception gives rise to anxiety and in turn mobilizes the defensive apparatus, including, of course, repression. Thus, because of the impending danger from unacceptable or dangerous impulses, the unpleasantness of anxiety produces the repression of the impulses, which in turn leads the organism out of danger.

Avoidance of overstimulation. It should be noted that a central concept in both of Freud’s theories of anxiety is the notion of the avoidance of overstimulation. Whether libido is dammed up by not executing some instinctual act or whether the ego signals impending stimulation that cannot be adequately handled, in both cases the anxiety anticipates an impending situation for which no adequate coping mechanism is available to the organism. The ultimate unpleasantness is overstimulation, including pain, and the anxiety in both theories signals or anticipates this prototypical state. Thus, Freud derives the origin of anxiety from the prototype of overstimulation. Such a derivation is necessary at least for the second theory, which presupposes cognitive, perceptual actions on the part of the ego. Here anxiety is learned; it is acquired as a function of past experience. It is in this sense that the psychoanalytic theory of anxiety, including its several revisions, has never abandoned the first theory, which describes the development of “automatic” anxiety. In the second theory, anxiety is derived from “automatic” anxiety; in the first theory, all anxiety is “automatic.”

Antecedent and organismic conditions. The origin of “automatic” anxiety is traced by Freud into the very earliest period of life, the birth trauma and the immediate period thereafter. Emphasis on the helpless infant as well as on the birth trauma as the origin of the anxiety state places him apart from Rank (1924), who relies solely on the birth trauma as the source of anxiety.

For Freud (1926), the experience of anxiety— as distinct from its antecedents or consequences or as a theoretical state—has three aspects: (1) a specific feeling of unpleasantness, (2) efferent or discharge phenomena, and (3) the organism’s perception of these discharge phenomena. In other words, the perception of autonomic arousal is associated with a specific feeling of unpleasantness. As to the primitive occasions for this anxiety experience, Freud is frequently hazy. While, on the one hand, he considers the predisposition toward anxiety as a genetic mechanism ([1916–1917] 1952) at other times he considers anxiety as arising from separation from the mother, castration fears, and other early experiences. He considers the specific unpleasant experience of the anxiety state as derived from the first experience of overstimulation at the time of birth. He says that the birth experience “involves just such a concatenation of painful feelings, of discharges and excitation, and of bodily sensations, as to have become a prototype for all occasions on which life is endangered, ever after to be reproduced again in us as the dread or ‘anxiety’ condition” (Freud [1916–1917] 1952, p. 344). Thus, it is possible that some of the discussions that have arisen out of several interpretations of Freud’s theory of anxiety have confused the specific experience of anxiety derived from the physiological make-up of the organism and the birth trauma with the conditions that produce or threaten unmanageable discharge. The conditions that produce such an anxiety state are, in addition to the birth trauma, separation or loss of the mother, with the attendant threat of overstimulation due to uncontrollable impulses and threats, and castration fears with similar consequences. Thus, where Rank places both the affect and the prototypic antecedent conditions at the period of birth, Freud lets the organism inherit or learn the affect at birth, but also adds other specific conditions that elicit it later on in early life. On this basis it is reasonable to claim, as Kubie (1941) does, “that all anxiety has as its core what Freud has called ‘free floating anxiety.’” In other words, given the initial affect of anxiety that a child either genetically or experientially brings into the world, specific anxieties and fears are then situationally developed out of this basic predisposition.

In this context, the various types of fears or anxieties that Freud discusses are not different in their initial source of the affect but, rather, differ in the specific conditions that give rise to them. They are fear, where anxiety is directly related to a specific object; objective anxiety (Realangst), which is the reaction to an external danger and which is considered to be not only a useful but also a necessary function of the system; and neurotic anxiety, in which the anxiety is out of proportion to the real danger and frequently is related to unacceptable instinctual impulses and unconscious conflicts.

Freud’s notion that anxiety is brought about when the ego receives those external or internal cues that signal helplessness or inability to cope with environmental or intrapsychic threats is mirrored in Karen Horney’s position that basic anxiety is “the feeling a child has of being isolated and helpless in a potentially hostile world” (Horney 1945, p. 41). For Horney, primary anxiety is related eventually to disturbances of interpersonal relations, initially those between the child and significant adults. A similar position is taken by Harry Stack Sullivan, who relates both parental disapproval to the development of anxiety and the inadequacies, irrationalities, and confusions of the cultural pattern to its elicitation.

In summary, the psychoanalytic position not only treats anxiety as an important tool for the adequate handling of a realistically threatening environment, but it also relates anxiety to the development of neurotic behavior. The “cultural” psychoanalysts then go on to stress the social environment at large, while Freud sees the basic anxiety mechanisms in the very early mother separation and castration fears. In all cases, however, anxiety is related to the inability of the organism to cope with a situation that threatens to overwhelm him, the absence of adequate acts to deal with environmental or intrapsychic events. As Freud phrased it in one of his later formulations, “anxiety . . . seems to be a reaction to the perception of the absence of the object [e.g., goal]” (Freud [1926] 1936). With the object absent, no action is possible and helplessness, i.e., anxiety, ensues.

Learning theory

The theoretical position taken by most representatives of modern learning or behavior theory is derived generally from the work of I. P. Pavlov and J. B. Watson. The two major positions are those of C. L. Hull and B. F. Skinner, although neither of these two men themselves have worked extensively on the problem of anxiety. Most of the work on anxiety, within the framework of learning theory, has been carried out by representatives of the Hullian school. While most of their experimental work has involved lower animals, the “conditioning” concept of anxiety has been extensively applied to complex human behavior (cf. Dollard & Miller 1950).

As Mowrer (1960) has shown, the role of anxiety for learning theory is derived mainly from the attempts to explain the nature and consequences of punishment. In the case of punishment, the application of some painful or noxious event following the performance of a response inhibits or interferes with the performance of that response on some subsequent occasion. Similarly, when an organism avoids a situation, it is, through the operation of some mediating mechanism, precluding the occurrence of a noxious or painful event. The nature of this mediating mechanism, learning theorists contend, is what is commonly called fear or anxiety.

Anxiety as an acquired drive. The conditioning model states that a previously neutral event or stimulus (the conditioned stimulus, or CS), when paired with an unconditioned stimulus (US), which produces a noxious state such as pain, will elicit a conditioned response (CR) after a suitable number of pairings. This conditioned response is what is commonly called fear. In a typical experimental situation, an animal might be placed in a white box

with a door leading to a black box. The floor of the white box is electrified, and the animal receives a shock (US) that becomes associated with the white box (CS). If the animal is then permitted to escape from the shock through the door to the black box, he will eventually run from the white to the black box prior to the application of shock. Learning theorists assert that the fear (CR) conditioned to the white box (CS) motivates subsequent activity. The reduction of the fear—by escape from the CS —thus produces avoidance of the original noxious unconditioned stimulus. Fear—or anxiety—is viewed as a secondary or acquired drive established by classical conditioning. While this basic paradigm has been extensively elaborated, it represents the basic notions about anxiety in modern learning theory.

The Skinnerian point of view has been described by Schoenfeld (1950), who argues against the notion that the organism “avoids” the unconditioned stimulus. He suggests that the organism in fact escapes from a stimulus array that consists of the conditioned stimulus as well as the proprioceptive and tactile stimuli, which precede the unconditioned stimulus. However, this description is not basically divergent from the more general statement that the proprioceptive and tactile stimuli are a conditioned response functioning as a drive [see Learning, article onavoidance learning; CONFLICT, article onpsychological aspects].

Antecedent conditions. Whether avoidance learning is achieved by the mediating effect of the conditioned fear or ascribed to conditioned aversive stimuli, the question still remains open as to the necessary characteristics of the original, unconditioned, noxious, or aversive stimulus. In one of the early statements on conditioned fear, Mowrer (1939) suggested that fear was the conditioned form of the pain response. However, it has been demonstrated that pain cannot be a necessary condition for the establishment of anxiety since individuals who are congenitally incapable of experiencing pain also show anxiety reactions. (For a summary of this argument, see Kessen & Mandler 1961.) In a more general statement about the nature of acquired drives such as fear, Miller (1951) has extended the class of unconditioned stimuli adequate for fear conditioning to essentially all noxious stimuli, and Mowrer (1960) comes close to a psychoanalytic position when he expresses essential agreement with the position that fear is a psychological warning of impending discomfort. However, work with experimental animals has failed to establish unequivocally that fear can be conditioned upon the onset of discomforting primary drives or USs other than those associated with painful stimuli. This failure hampers the generality of the conditioning model.

Organismic conditions. The above evidence becomes important when one considers not only the antecedent conditions for the establishment of fear, which the learning theorists relate to the conditioning paradigm, but also the nature of the mediating response (the CR). A variety of data (for example, Wynne & Solomon 1955) has shown that the development of the anxiety or fear state in animals depends upon an adequately functioning autonomic nervous system. Thus, within the confines of the conditioning model, those writers who have speculated upon the nature of the mediating fear or anxiety state have suggested that it presupposes some sympathetic arousal. It follows from this that fear or anxiety can be conditioned only if the unconditional stimulus also is one that produces such sympathetic or general autonomic effects. To the extent then that a learning theory position assumes emotional, autonomic responses correlated with the fear state, it also suggests that fear necessarily derives only from those primary conditions that in turn are autonomically arousing. Thus, at least as far as such writers as Mowrer are concerned, the threat of discomfort, or rise in primary drives, or overstimulation in general, can only be prototypes for anxiety if, and only if, these states in turn have autonomic components. However, this does not seem to be the case for such divergent states as hunger, thirst, and so forth.

Consequent conditions. As far as the consequences of conditioned fear are concerned, there seems to be general agreement, both theoretical and empirical, that they fall into two general classes. In the first class, fear and anxiety operate as secondary drives and exhibit all the usual properties of drives, serving as motives for the establishment of new behavior. When fear acts as a drive, new responses are reinforced by the reduction of that drive. This response-produced drive is the major emphasis that learning theory has placed on fear or anxiety. In the second class, it has also been recognized that the conditioned fear response or the CER (conditioned emotional response) may in a variety of situations interfere with or suppress ongoing behavior. In this sense, it is of course no different from the general anxiety concept of the psychoanalysts in that behavioral anxiety or preoccupation with anxiety may be incompatible with other behavior or thoughts required from the organism in a particular situation.

Existentialist psychology

The emergence of existentialism from a purely philosophical school to an important influence on psychology has been a phenomenon of the mid-twentieth century. What existentialist thinking has done for psychology is not so much to present it with a new theory in the tradition of well-defined deductive positions that became popular in the early part of the century, but rather to provide it with a wealth of ideas and challenges to conventional wisdom. While a variety of different positions and schools can be discerned within the movement, the problem of anxiety has remained essentially unchanged from Kierkegaard’s pathbreaking formulation, published more than a hundred years ago (1844). For example, Jean-Paul Sartre’s position about the problem of anxiety is, for present purposes, not noticeably at variance with it (1943). Kierkegaard’s central concept of human development and human maturity was the notion of freedom. Freedom is related to man’s ability to become aware of the wide range of possibility facing him in life —possibility in that sense is not statically present in his environment but created and developed by man. Freedom implies the existence and awareness of possibility.

Anxiety is intimately tied up with this existence of possibility and potential freedom. The very consideration of possibility brings with it the experience of anxiety. Whenever man considers possibilities and potential courses of action, he is faced with anxiety. Whenever the individual attempts to carry any possibility into action, anxiety is a necessary accompaniment, and growth toward freedom means the ability to experience and tolerate the anxiety that necessarily comes with the consideration of possibility. In modern terms, any choice situation involves the experience of anxiety, and thus for the existentialist position the antecedents of anxiety are, in a sense, the very existence of man in a world in which choice exists.

Kierkegaard endows even the newborn child with an unavoidable and necessary prototypical state of anxiety. However, since the child is originally in what Kierkegaard calls a “state of innocence,” a state in which he is not yet aware of the specific possibilities facing him, his anxiety too is an anxiety that is general but without content. Possibility exists, but it is a possibility of action in general, not of specific choices. The peculiarly human problem of development faces the child as he becomes aware both of himself and of his environment. Possibility and actualization become specific, and anxiety appears at each point where development and individuation of the child progresses; at each point a new choice of possibilities must be faced, and anxiety must be confronted anew.

The consequences of this notion of anxiety are that as the individual develops he is continuously confronted with the unpleasant experience of anxiety and with the problem of mature development in the face of it. It is not only unavoidable as a condition of man; it is, Kierkegaard maintains, actually sought out. “Anxiety is an alien power which lays hold of an individual, and yet one cannot tear oneself away, nor has the will to do so; for one fears, but what one fears one desires. Anxiety then makes the individual impotent” (Kierkegaard [1844] 1944, p. xii). Since anxiety is unavoidable and since it must be encountered if one is to grow as a human being, all attempts at avoiding the experience of anxiety are either futile, or they result in a constricted, uncreative, and unrealistic mode of life. Only by facing the experience of anxiety can one truly become an actualized human being and face the reality of human existence.

Kierkegaard also makes a clear distinction between fear and anxiety. Fear involves a specific object that is feared and avoided, whereas anxiety is independent of the object and furthermore is a necessary attribute of all choice and possibility.

The importance of Kierkegaard, and the existentialist development in general, is not the emergence of testable scientific propositions, but rather the emphasis—found inter alia in some psychoanalytic writings—that anxiety may not be primarily a learned experience derived from past encounters with painful environmental events, but may be a naturally occurring initial state of the organism. Man may in fact be born with anxiety, rather than learn it through experience. While existentialism has not produced any clear definitions of anxiety, apart from appealing to an assumed common phenomenology, it has raised important questions both about the general problem of anxiety and, in the field of psychotherapy, about the proper treatment for those conditions that show pathological effects of anxiety. It is quite clear that a therapeutic attitude that considers anxiety as a normal state is radically different from an attitude that stresses the avoidance of primary and secondary traumata [see Psychology, article on EXISTENTIAL psychology].

Human anxiety—empirical generalizations

Since 1950, when May remarked on the absence of the problem of human anxiety from strictly experimental concerns (1950, p. 99), literally hundreds of studies have been published, using a quantitative, experimental approach to the problem of human anxiety. Many investigations have used the concept of anxiety primarily as an explanatory rather than as a manipulated variable. These studies fall more properly under such rubrics as conflict, stress, frustration, etc. and will not be dealt with here. However, a large body of research has been devoted specifically to anxiety. This rash of experimental investigations was in the first instance instigated by the development of the socalled anxiety scales. The most widely used and influential of these is the Manifest Anxiety Scale, developed by Janet Taylor Spence (Taylor 1953).

Manifest Anxiety Scale

The Manifest Anxiety Scale was originally developed to test some of the implications of the anxiety or fear concept within the general system originated by C. L. Hull. By developing a scale that would order individuals along a continuum of anxiety, it was expected that individuals who had high anxiety scores would exhibit more general drive level than individuals with less anxiety, since anxiety is—within this theoretical position—considered to be a secondary, or acquired, drive.

The Manifest Anxiety Scale consists of 50 items from the Minnesota Multiphasic Personality Inventory, all of which are judged to be indexes of high emotionality or anxiety. Typical items are: I am easily embarrassed (if answered “true”); I do not have as many fears as my friends (if answered “false”). Experimental work with this scale bore out the primary prediction: individuals scoring high on this scale (i.e., who are highly anxious) acquire conditioned responses based on aversive unconditioned stimuli much more rapidly than individuals scoring low on the scale. This is certainly the case for eyeblink conditioning, and the evidence is in the same direction for the conditioning of the galvanic skin response. However, these predictions from drive theory do not seem to hold for nonaversive conditioning, and it has been suggested that the anxiety drive measured by the Manifest Anxiety Scale is reactive rather than chronic. In other words, an individual with high anxiety shows anxiety in situations in which there is an element of threat or even conflict, and he apparently does not react with high drive in all situations.

A further prediction from Hullian theory was that individuals with high anxiety should perform better on simple tasks than on complex ones, but that individuals with little anxiety should perform better on complex tasks. This prediction, too, has generally been borne out (Taylor 1956). Finally, even though the scale was not directly constructed to evaluate clinical levels of anxiety, it does show consistently positive correlations with clinical judgments of anxiety in both patient and normal populations.

Test Anxiety Questionnaire

Whereas the Manifest Anxiety Scale concentrated on the drive aspects of anxiety, the other widely used anxiety scale has been more specifically concerned with interfering responses generated by the anxiety state. The Test Anxiety Questionnaire was originally developed by G. Mandler and S. B. Sarason (1952). It consists of 37 graphic scales specifically concerned with the experience of anxiety in test or examination situations. The hypothesis suggested that the more an individual tends to report the occurrence of anxietylike experiences on a questionnaire, the more likely it is that these will occur in any situation that involves examination or test pressures such as potential success or failure, time pressures, and so forth. In contrast to experiments with the Manifest Anxiety Scale, studies of the Test Anxiety Questionnaire have tended to stress rather complex tasks and complex instructions to the subjects. In general, here too the predictions about the interfering nature of anxiety in complex situations have been borne out. Subjects with high anxiety do tend to show interfering or task-irrelevant responses when faced with a task that seems to imply ego involvement or potential failure.

Correlational studies of the two scales have shown a low positive relationship, but the Manifest Anxiety Scale seems to tap more general characteristics of the individual, while the Test Anxiety Questionnaire is more sensitive to situational cues, particularly those that indicate to the subject that he is being tested or examined. Both kinds of scales, however, suggest that anxietylike responses will occur when some cue indicating threat is presented, whether it be an aversive unconditioned stimulus or a test situation. In that sense, the scales are tapping personality differences in the tendency to experience anxiety to a greater or lesser degree.

Finally, J. W. Atkinson has related anxiety, as reported on the Test Anxiety Questionnaire, to a more general system of motivation by using this scale as a measure of a general motive to avoid failure (e.g., Atkinson & Litwin 1960). Attempts of this nature and the general placement of the personality dimension of anxiety within a more general system of motivation (e.g., Spence 1958) are needed to integrate the hundreds of empirical studies that have used the various anxiety scales.

One other important set of experimental studies that have specifically dealt with anxiety has been reported by Schachter (1959). These studies have

shown that affiliative behavior is related to self-reported anxiety. Schachter also demonstrated that the presentation of a fear-arousing situation tended to arouse affiliative needs, such as the desire to be with others. His data suggest that stimuli unrelated to the threat may result in anxiety reduction; flight from trauma or its signals is not the only method of avoiding anxiety.

Anxiety—an integrative point of view

Certain commonalities can be found among the various theoretical views of anxiety, and all of these seem to be fairly consistent with the experiential and experimental evidence available. There is agreement that anxiety, as a mediating, experiential phenomenon, is related to the perception of impending threat, or overstimulation, or unmanageable demands and that it is accompanied by a discharge in the sympathetic nervous system. It seems also fairly well agreed that the consequences of anxiety may, in the face of an aversive event, be motivating in the sense that they make it possible for the organism to avoid the threat or danger more quickly and efficiently. Both learning theory and existential theory, surprisingly, seem to stress the importance of anxiety in making it possible for the organism to handle threatening situations, even though they might disagree about the nature of these threats. It also seems to be generally agreed that anxiety may also interfere with complex, usually cognitive, activities of the organism. There seems to be less agreement on the origin of the anxiety reaction. In psychoanalytic and learning theories the stress seems to be on some early traumatic event, while the existentialists tend to favor anxiety as a built-in characteristic of the human organism. But even here some of the psychoanalytic positions can be read as consistent with the existentialist point of view.

Some recent observations on the behavior of the newborn child and some speculations on the inadequacy of the pain experience as the foundation of all of anxiety have resulted in a series of proposals that seem to provide a broad basis for the many different theoretical conceptions. The position in question suggests that some of the psychoanalytic and existentialist assumptions about the origins of anxiety are essentially correct. There is good reason to believe that the newborn infant is, in fact, in a state of variable, spontaneous, and sometimes intense autonomic arousal. This state of arousal is correlated with a general state of infantile distress. It is certainly the case that the newborn infant shows cyclic states of distress that cannot easily be related to antecedent stimulation. It may in fact be the case that the relatively well-regulated autonomic system of the adult is a result of acquired and systematic regulation. In any case, infantile distress can be seen as the prototype of the distress that is later called anxiety, in the absence of specific environmental events, or fear, in the presence of specific stimuli. Given this general cyclical state of distress, it can also be shown that a child can be quieted by a set of environmental or organismic events that have been designated as inhibitors (Kessen & Mandler 1961). Sucking is the best-known and most intensively investigated of these inhibitors. Sucking, rocking, and other activities seem to inhibit or quiet the distress of the child. It is possible that these acts stimulate parasympathetic activity that counteracts the sympathetic discharge. It also appears that with maturation not only these apparently innate inhibitors but a whole class of secondary, probably conditioned, inhibitors also acquires this quieting or anxiety-suppressing property. On the other hand, the removal of these inhibitors or the interruption of any organized activity (Mandler 1964) appears to reinstate the general state of distress or anxiety. This view suggests that from a state of congenitally given autonomic and behavioral distress the child moves into a situation in which more and more acts and events tend to acquire the property to inhibit distress, and their removal tends to reinstate it.

Starting with Kurt Lewin’s work (1935), it has been shown that interruption of well-organized behavior leads to a state of anxiety. Therefore, it is suggested that while, for the young child, there is only a limited repertory of events and behaviors available that will inhibit or control the basic state of distress, any organized activity in the older child and in an adult will do so, and that finally any organized activity serves to ward off the state of distress. Conversely, it might be stated that whenever the organism has no well-organized behavior available to him, he is in a state of distress. Thus, whenever the organism is not able to draw upon some behavior or act that controls his environment, that is, whenever he is in a condition of helplessness, unable to control stimulation or environmental input in general, he will be in a state of anxiety.

This view is consistent with the psychoanalytic tenets on overstimulation and Freud’s statement about anxiety being related to the loss of the object. When either overstimulation threatens or no object (goal) is present, the organism has no behavior available to him and cannot act; therefore he is anxious. As far as the existentialist position is concerned, the state of anxiety occurs, of course, whenever the individual has no way of coping with environmental demands; in other words, no way of confronting possibility, no way of overcoming the anxiety that goes with possibility and freedom. Finally, the noxious, painful unconditioned stimulus of learning theory typically is an event that is unmanageable, represents overstimulation, and disrupts ongoing behavior. When the organism does in fact find a way of coping with this situation by escape, this escape behavior is the way of overcoming helplessness vis-à-vis the noxious stimulus and will appear upon a signal (the conditioned stimulus) prior to the occurrence of the unconditioned stimulus.

Finally, the data on highly anxious individuals suggest that these are people who have very few mechanisms available for coping with helplessness or threat. They are in fact frequently faced with a world in which no behaviors are available for them to inhibit or avoid the threat of helplessness.

Anxiety neurosis

The most important pathological manifestation of the anxiety reaction is seen in the syndrome commonly called anxiety neurosis. While anxiety presumably plays a role in all neurotic disorders, this syndrome has both the overt and the subjective aspects of anxiety as its primary characteristics. The anxiety neurotic is the patient who is incapacitated by continuous and often nonspecific feelings of anxiety. Whereas anxiety in the other neuroses, particularly in the phobias, is aroused by a specific condition or set of internal or external stimuli, in the anxiety neurotic any and all external situations or thoughts may give rise to an anxiety reaction. The patient typically displays signs of apprehensiveness and fearfulness in a variety of different situations, none of which can necessarily be objectively described as threatening or aversive. While the patient may in some cases ascribe specific fearfulness to some stimulus, he will frequently find himself in situations that never before have aroused anxiety and now suddenly acquire the power to do so. Thus, while he may name a long list of thoughts or events of which he is afraid or apprehensive, he will just as frequently describe the general phenomenon of free-floating anxiety, a feeling of distress or apprehensiveness with no specific content.

Apart from the subjective feelings that accompany the general anxious state of the patient, he will usually exhibit somatic symptoms, particularly those that are in a milder form associated with the typical normal anxiety reaction. In general, he will show heightened autonomic arousal, cardiac involvement, breathing difficulties, excessive sweating, and so forth. These will frequently be accompanied by skeletal symptoms such as trembling and startle reactions. Both the intensity and the duration of the anxiety attacks may vary. They may range from a continuous feeling of uneasiness and distress to sudden, panicky attacks that may last for minutes or hours.

Since all situations are potentially cues for the anxiety reaction, the patient frequently tends to be immobilized and unable to act or plan over long periods of time.

Relatively little is known about the genesis of this pathological state, although experimental work has shown that the equivalent of the anxiety neurosis may be produced in lower animals by the presentation of unsolvable conflicts. Case histories of anxiety neurotics also generally show their backgrounds as being replete with continuous conflicts coupled with feelings of inadequacy and inferiority. Just as the experimental animal is unable to resolve the conflict between hunger and fear of shock when he has been shocked at the time and place of feeding, so the human is unable to act in the face of two conflicting motives.

For both psychoanalytic theory and learning theory, the conditions that produce the pathological anxiety reaction are seen in the inability of the patient to discriminate threatening from non-threatening events and ideas. From a psychoanalytic point of view, infantile fears and fantasies are kept unconscious but produce an interpretation of danger in a wide variety of otherwise neutral situations. Many different stimuli reactivate childhood conflicts, and the ego, which is otherwise functioning normally, interprets as dangerous a wide variety of different situations. Another possibility is that aspects of parental behavior during early childhood training have produced the tendency to identify many different situations as dangerous.

The somewhat similar interpretation given by learning theory suggests that anxiety neurosis is the result of an overgeneralization of the original conditioned stimuli for the anxiety reaction. Whereas in the normal adult the generalization gradient in conditioning is relatively steep, the anxiety neurotic manifests a very flat generalization gradient from the original conditioned stimuli. The anxiety reaction is elicited by a wide variety of stimuli that may be only vaguely similar to the original conditioned stimulus, with verbal mediators playing an important role in generalizing to new situations. In addition, both learning theory and psychoanalytic theory suggest that the patient not only becomes afraid of the original conditioned stimulus and similar ones, but also the anxiety reaction itself becomes a conditioned stimulus for a new fear reaction, resulting in a vicious cycle of increasing anxiety eventually reaching panic levels.

Both of these positions suggest that the pathological condition of the anxiety reaction is somehow derivable from one or several early nuclear experiences. Another possibility consistent with clinical observation of anxiety neurotics relates the sources of the anxiety reaction to a generalized feeling of helplessness. The anxiety patient will practically invariably describe his subjective state as one of conflict or helplessness. He feels unable to act because he does not know how to act; he vacillates because he does not know what to do; he cannot defend one course of action as preferable to another. Conflict may arise out of the competition of two equally strong reaction tendencies; it may also derive from the fact that no one reaction tendency is, by itself, organized well enough to be executed. In other words, the inability to choose an act, the fear of facing the consequences of an act once chosen, or a general lack of confidence that any behavior could possibly be adaptive or successful may by themselves lead to anxiety. The pathological condition of the anxiety neurotic is thus related to the inability to face choices and to make choices: he is anxious because he is in conflict, and he is in conflict because he is anxious.

Finally, the genesis of the pathological anxiety reaction may not only be derived from an environment that endows a variety of thoughts and events with the label “danger” but may also be related to the individual’s reaction to his physiological responses. One theory of emotion claims that the basic physiological substratum of all emotions is similar (i.e., a sympathetic nervous system reaction) and that the content of the emotion depends on cognitive or environmental factors, suggesting that a combination of physiological readiness and helplessness in view of environmental demands is basic to the problem of the anxiety neurotic (Schachter 1964; Mandler 1962). Such a position would indicate that one of the things the anxiety neurotic may not have learned is adequate labeling of his autonomic responses. In the absence of such adequate labeling or in case of hypersensitivity or hyperattention to such arousal, an individual would be much more likely to experience anxiety whenever faced with a situation in which no adequate response is available. In this sense, the problem of the anxiety neurotic may be exactly opposite to that of the psychopath who experiences too little anxiety (Schachter 1964).

George Mandler

[Other relevant material may be found underDrives; Emotion; Motivation; Psychoanalysis; Stress.]

BIBLIOGRAPHY

Atkinson, John W.; and Litwin, George H. 1960 Achievement Motive and Test Anxiety Conceived as Motive to Approach Success and Motive to Avoid Failure. Journal of Abnormal and Social Psychology 60:52–63.

Bain, Alexander (1859) 1899 The Emotions and the Will. 4th ed. London: Longmans.

Cameron, Norman A. 1963 Personality Development and Psychopathology: A Dynamic Approach. Boston: Houghton Mifflin. → An excellent discussion of pathological anxiety states within the general framework of psychopathology.

Cofer, Charles N.; and Appley, Mortimer H. 1964 Motivation: Theory and Research. New York: Wiley. → A survey that places anxiety within the general framework of motivational theory and data.

Dollard, John; and Miller, Neal E. 1950 Personality and Psychotherapy: An Analysis in Terms of Learning, Thinking, and Culture. New York: McGraw-Hill.

Freud, Sigmund (1916–1917) 1952 A General Introduction to Psychoanalysis. Authorized English translation of the rev. ed. by Joan Riviere. Garden City, N.Y.: Doubleday. → First published as Vorlesungen zur Einführung in die Psychoanalyse.

Freud, Sigmund (1926) 1936 The Problem of Anxiety. New York: Norton. → First published as Hemmung, Symptom und Angst. The British translation was published by Hogarth, London, in 1936 as Inhibitions, Symptoms and Anxiety. Pages cited in text refer to the American edition.

Horney, Karen 1945 Our Inner Conflicts: A Constructive Theory of Neurosis. New York: Norton.

Kessen, William; and Mandler, George 1961 Anxiety, Pain, and the Inhibition of Distress. Psychological Review 68:396–404.

Kierkegaard, SØren A. (1844) 1957 The Concept of Dread. 2d ed. Princeton Univ. Press. → First published as Begrebet angest.

Kubie, Lawrence S. 1941 A Physiological Approach to the Concept of Anxiety. Psychosomatic Medicine 3:263–276.

Lewin, Kurt 1935 A Dynamic Theory of Personality: Selected Papers. New York: McGraw-Hill.

Mandler, George 1962 Emotion. Pages 267–343 in Roger Brown et al., New Directions in Psychology. New York: Holt.

Mandler, George 1964 The Interruption of Behavior. Volume 12, pages 163-219 in David Levine (editor), Nebraska Symposium on Motivation, 1964. Lincoln: Univ. of Nebraska Press.

Mandler, George; and Sarason, Seymour B. 1952 A Study of Anxiety and Learning. Journal of Abnormal and Social Psychology 47:166–173.

May, Rollo 1950 The Meaning of Anxiety. New York: Ronald Press. → An excellent survey and integration of the many meanings of anxiety.

Miller, Neal E. 1951 Learnable Drives and Rewards. Pages 435–472 in Stanley S. Stevens (editor), Handbook of Experimental Psychology. New York: Wiley.

Mowrer, Orval H. 1939 Stimulus-Response Analysis of Anxiety and Its Role as a Reinforcing Agent. Psychological Review 46:553–565.

Mowrer, Orval H. 1960 Learning Theory and Behavior. New York: Wiley.

Rank, Otto (1924) 1952 The Trauma of Birth. New York: Brunner. → First published as Das Trauma der Geburt.

Sartre, Jean-Paul (1943) 1956 Being and Nothingness: An Essay on Phenomenological Ontology. New York: Philosophical Library. → First published as L’être et le néant, essai d’ontologie phénoménologique.

Schachter, Stanley 1959 The Psychology of Affiliation: Experimental Studies of the Sources of Gregariousness. Stanford Studies in Psychology, No. 1. Stanford Univ. Press.

Schachter, Stanley; and LatanÉ, bibb 1964 Crime, Cognition and the Autonomic Nervous System. Volume 12, pages 221–275 in David Levine (editor), Nebraska Symposium on Motivation: 1964. Lincoln: Univ. of Nebraska Press. → Includes two pages of comment by George Mandler.

Schoenfeld, William N. 1950 An Experimental Approach to Anxiety, Escape and Avoidance Behavior. Pages 70-99 in Paul H. Hoch and Joseph Zubin (editors), Anxiety. New York: Grune.

Spence, Kenneth W. 1958 A Theory of Emotionally Based Drive (D) and Its Relation to Performance in Simple Learning Situations. American Psychologist 13:131–141.

Taylor, Janet A. 1953 A Personality Scale of Manifest Anxiety. Journal of Abnormal and Social Psychology 48:285–290.

Taylor, Janet A. 1956 Drive Theory and Manifest Anxiety. Psychological Bulletin 53:303–320.

Wynne, Lyman C.; and Solomon, Richard L. 1955 Traumatic Avoidance Learning: Acquisition and Extinction in Dogs Deprived of Normal Peripheral Autonomic Function. Genetic Psychology Monographs 52: 241–284.

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Anxiety

Anxiety

Definition

Anxiety is a multisystem response to a perceived threat or danger. It reflects a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation. As far as we know, anxiety is a uniquely human experience. Other animals clearly know fear, but human anxiety involves an ability, to use memory and imagination to move backward and forward in time, that animals do not appear to have. The anxiety that occurs in posttraumatic syndromes indicates that human memory is a much more complicated mental function than animal memory. Moreover, a large portion of human anxiety is produced by anticipation of future events. Without a sense of personal continuity over time, people would not have the "raw materials" of anxiety.

It is important to distinguish between anxiety as a feeling or experience, and an anxiety disorder as a psychiatric diagnosis. A person may feel anxious without having an anxiety disorder. In addition, a person facing a clear and present danger or a realistic fear is not usually considered to be in a state of anxiety. In addition, anxiety frequently occurs as a symptom in other categories of psychiatric disturbance.

Description

Although anxiety is a commonplace experience that everyone has from time to time, it is difficult to describe concretely because it has so many different potential causes and degrees of intensity. Doctors sometimes categorize anxiety as an emotion or an affect depending on whether it is being described by the person having it (emotion) or by an outside observer (affect). The word emotion is generally used for the biochemical changes and feeling state that underlie a person's internal sense of anxiety. Affect is used to describe the person's emotional state from an observer's perspective. If a doctor says that a patient has an anxious affect, he or she means that the patient appears nervous or anxious, or responds to others in an anxious way (for example, the individual is shaky, tremulous, etc.).

KEY TERMS

Affect An observed emotional expression or response. In some situations, anxiety would be considered an inappropriate affect.

Anxiolytic A type of medication that helps to relieve anxiety.

Autonomic nervous system (ANS) The part of the nervous system that supplies nerve endings in the blood vessels, heart, intestines, glands, and smooth muscles, and governs their involuntary functioning. The autonomic nervous system is responsible for the biochemical changes involved in experiences of anxiety.

Endocrine gland A ductless gland, such as the pituitary, thyroid, or adrenal gland, that secretes its products directly into the blood or lymph.

Free-floating anxiety Anxiety that lacks a definite focus or content.

Hyperarousal A state or condition of muscular and emotional tension produced by hormones released during the fight-or-flight reaction.

Hypothalamus A portion of the brain that regulates the autonomic nervous system, the release of hormones from the pituitary gland, sleep cycles, and body temperature.

Limbic system A group of structures in the brain that includes the hypothalamus, amygdala, and hippocampus. The limbic system plays an important part in regulation of human moods and emotions. Many psychiatric disorders are related to malfunctioning of the limbic system.

Phobia In psychoanalytic theory, a psychological defense against anxiety in which the patient displaces anxious feelings onto an external object, activity, or situation.

Although anxiety is related to fear, it is not the same thing. Fear is a direct, focused response to a specific event or object, and the person is consciously aware of it. Most people will feel fear if someone points a loaded gun at them or if they see a tornado forming on the horizon. They also will recognize that they are afraid. Anxiety, on the other hand, is often unfocused, vague, and hard to pin down to a specific cause. In this form it is called free-floating anxiety. Sometimes anxiety being experienced in the present may stem from an event or person that produced pain and fear in the past, but the anxious individual is not consciously aware of the original source of the feeling. It is anxiety's aspect of remoteness that makes it hard for people to compare their experiences of it. Whereas most people will be fearful in physically dangerous situations, and can agree that fear is an appropriate response in the presence of danger, anxiety is often triggered by objects or events that are unique and specific to an individual. An individual might be anxious because of a unique meaning or memory being stimulated by present circumstances, not because of some immediate danger. Another individual looking at the anxious person from the outside may be truly puzzled as to the reason for the person's anxiety.

Causes and symptoms

Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person's environment, or a response to an internal stimulus (for example, a hypochondriac's reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.

Physical

In some cases, anxiety is produced by physical responses to stress, or by certain disease processes or medications.

THE AUTONOMIC NERVOUS SYSTEM (ANS). The nervous system of human beings is "hard-wired" to respond to dangers or threats. These responses are not subject to conscious control, and are the same in humans as in lower animals. They represent an evolutionary adaptation to the animal predators and other dangers with which all animals, including primitive humans, had to cope. The most familiar reaction of this type is the so-called "fight-or-flight" response. This response is the human organism's automatic "red alert" in a life-threatening situation. It is a state of physiological and emotional hyperarousal marked by high muscle tension and strong feelings of fear or anger. When a person has a fight-or-flight reaction, the level of stress hormones in their blood rises. They become more alert and attentive, their eyes dilate, their heartbeat increases, their breathing rate increases, and their digestion slows down, allowing more energy to be available to the muscles.

This emergency reaction is regulated by a part of the nervous system called the autonomic nervous system, or ANS. The ANS is controlled by the hypothalamus, a specialized part of the brainstem that is among a group of structures called the limbic system. The limbic system controls human emotions through its connections to glands and muscles; it also connects to the ANS and "higher" brain centers, such as parts of the cerebral cortex. One problem with this arrangement is that the limbic system cannot tell the difference between a realistic physical threat and an anxiety-producing thought or idea. The hypothalamus may trigger the release of stress hormones by the pituitary gland, even when there is no external and objective danger. A second problem is caused by the biochemical side effects of too many "false alarms" in the ANS. When a person responds to a real danger, his or her body gets rid of the stress hormones by running away or by fighting. In modern life, however, people often have fight-or-flight reactions in situations in which they can neither run away nor lash out physically. As a result, their bodies have to absorb all the biochemical changes of hyperarousal, rather than release them. These biochemical changes can produce anxious feelings, as well as muscle tension and other physical symptoms associated with anxiety. They may even produce permanent changes in the brain, if the process occurs repeatedly. Moreover, chronic physical disorders, such as coronary artery disease, may be worsened by anxiety, as chronic hyperarousal puts undue stress on the heart, stomach, and other organs.

DISEASES AND DISORDERS. Anxiety can be a symptom of certain medical conditions. Some of these diseases are disorders of the endocrine system, such as Cushing's syndrome (overproduction of cortisol by the adrenal cortex), and include over- or underactivity of the thyroid gland. Other medical conditions that can produce anxiety include respiratory distress syndrome, mitral valve prolapse, porphyria, and chest pain caused by inadequate blood supply to the heart (angina pectoris).

A study released in 2004 showed that people who had experienced traumatic bone injuries may have unrecognized anxiety in the form of post-traumatic stress disorder. This disorder can result from witnessing or experiencing an event involving serious injury, or threatened death (or experiencing the death or threatened death of another.)

MEDICATIONS AND SUBSTANCE USE. Numerous medications may cause anxiety-like symptoms as a side effect. They include birth control pills; some thyroid or asthma drugs; some psychotropic agents; occasionally, local anesthetics; corticosteroids; antihypertensive drugs; and nonsteroidal anti-inflammatory drugs (like flurbiprofen and ibuprofen).

Although people do not usually think of caffeine as a drug, it can cause anxiety-like symptoms when consumed in sufficient quantity. Patients who consume caffeine rich foods and beverages, such as chocolate, cocoa, coffee, tea, or carbonated soft drinks (especially cola beverages), can sometimes lower their anxiety symptoms simply by reducing their intake of these substances.

Withdrawal from certain prescription drugs, primarily beta blockers and corticosteroids, can cause anxiety. Withdrawal from drugs of abuse, including LSD, cocaine, alcohol, and opiates, can also cause anxiety.

Learned associations

Some aspects of anxiety appear to be unavoidable byproducts of the human developmental process. Humans are unique among animals in that they spend an unusually long period of early life in a relatively helpless condition, and a sense of helplessness can lead to anxiety. The extended period of human dependency on adults means that people may remember, and learn to anticipate, frightening or upsetting experiences long before they are capable enough to feel a sense of mastery over their environment. In addition, the fact that anxiety disorders often run in families indicates that children can learn unhealthy attitudes and behaviors from parents, as well as healthy ones. Also, recurrent disorders in families may indicate that there is a genetic or inherited component in some anxiety disorders. For example, there has been found to be a higher rate of anxiety disorders (panic) in identical twins than in fraternal twins.

CHILDHOOD DEVELOPMENT AND ANXIETY. Researchers in early childhood development regard anxiety in adult life as a residue of childhood memories of dependency. Humans learn during the first year of life that they are not self-sufficient and that their basic survival depends on the care of others. It is thought that this early experience of helplessness underlies the most common anxieties of adult life, including fear of powerlessness and fear of being unloved. Thus, adults can be made anxious by symbolic threats to their sense of competence and/or significant relationships, even though they are no longer helpless children.

SYMBOLIZATION. The psychoanalytic model gives considerable weight to the symbolic aspect of human anxiety; examples include phobic disorders, obsessions, compulsions, and other forms of anxiety that are highly individualized. The length of the human maturation process allows many opportunities for children and adolescents to connect their experiences with certain objects or events that can bring back feelings in later life. For example, a person who was frightened as a child by a tall man wearing glasses may feel panicky years later by something that reminds him of that person or experience without consciously knowing why.

Freud thought that anxiety results from a person's internal conflicts. According to his theory, people feel anxious when they feel torn between desires or urges toward certain actions, on the one hand, and moral restrictions, on the other. In some cases, the person's anxiety may attach itself to an object that represents the inner conflict. For example, someone who feels anxious around money may be pulled between a desire to steal and the belief that stealing is wrong. Money becomes a symbol for the inner conflict between doing what is considered right and doing what one wants.

PHOBIAS. Phobias are a special type of anxiety reaction in which the person's anxiety is concentrated on a specific object or situation that the person then tries to avoid. In most cases, the person's fear is out of all proportion to its "cause." Prior to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), these specific phobias were called simple phobias. It is estimated that 10-11% of the population will develop a phobia in the course of their lives. Some phobias, such as agoraphobia (fear of open spaces), claustrophobia (fear of small or confined spaces), and social phobia, are shared by large numbers of people. Others are less common or unique to the patient.

Social and environmental stressors

Anxiety often has a social dimension because humans are social creatures. People frequently report feelings of high anxiety when they anticipate and, therefore, fear the loss of social approval or love. Social phobia is a specific anxiety disorder that is marked by high levels of anxiety or fear of embarrassment in social situations.

Another social stressor is prejudice. People who belong to groups that are targets of bias are at higher risk for developing anxiety disorders. Some experts think, for example, that the higher rates of phobias and panic disorder among women reflects their greater social and economic vulnerability.

Some controversial studies indicate that the increase in violent or upsetting pictures and stories in news reports and entertainment may raise the anxiety level of many people. Stress and anxiety management programs often suggest that patients cut down their exposure to upsetting stimuli.

Anxiety may also be caused by environmental or occupational factors. People who must live or work around sudden or loud noises, bright or flashing lights, chemical vapors, or similar nuisances, which they cannot avoid or control, may develop heightened anxiety levels.

Existential anxiety

Another factor that shapes human experiences of anxiety is knowledge of personal mortality. Humans are the only animals that appear to be aware of their limited life span. Some researchers think that awareness of death influences experiences of anxiety from the time that a person is old enough to understand death.

Symptoms of anxiety

In order to understand the diagnosis and treatment of anxiety, it is helpful to have a basic understanding of its symptoms.

SOMATIC. The somatic or physical symptoms of anxiety include headaches, dizziness or lightheadedness, nausea and/or vomiting, diarrhea, tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands. These symptoms are produced by the hormonal, muscular, and cardiovascular reactions involved in the fight-or-flight reaction. Children and adolescents with generalized anxiety disorder show a high percentage of physical complaints.

BEHAVIORAL. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, or finger tapping.

COGNITIVE. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion, or inability to concentrate.

EMOTIONAL. Feeling states associated with anxiety include tension or nervousness, feeling "hyper" or "keyed up," and feelings of unreality, panic, or terror.

DEFENSE MECHANISMS. In psychoanalytic theory, the symptoms of anxiety in humans may arise from or activate a number of unconscious defense mechanisms. Because of these defenses, it is possible for a person to be anxious without being consciously aware of it or appearing anxious to others. These psychological defenses include:

  • Repression. The person pushes anxious thoughts or ideas out of conscious awareness.
  • Displacement. Anxiety from one source is attached to a different object or event. Phobias are an example of the mechanism of displacement in psychoanalytic theory.
  • Rationalization. The person justifies the anxious feelings by saying that any normal person would feel anxious in their situation.
  • Somatization. The anxiety emerges in the form of physical complaints and illnesses, such as recurrent headaches, stomach upsets, or muscle and joint pain.
  • Delusion formation. The person converts anxious feelings into conspiracy theories or similar ideas without reality testing. Delusion formation can involve groups as well as individuals.

Other theorists attribute some drug addiction to the desire to relieve symptoms of anxiety. Most addictions, they argue, originate in the use of mood-altering substances or behaviors to "medicate" anxious feelings.

Diagnosis

The diagnosis of anxiety is difficult and complex because of the variety of its causes and the highly personalized and individualized nature of its symptom formation. There are no medical tests that can be used to diagnose anxiety by itself. When a doctor examines an anxious patient, he or she will first rule out physical conditions and diseases that have anxiety as a symptom. Apart from these exclusions, the physical examination is usually inconclusive. Some anxious patients may have their blood pressure or pulse rate affected by anxiety, or may look pale or perspire heavily, but others may appear physically completely normal. The doctor will then take the patient's medication, dietary, and occupational history to see if they are taking prescription drugs that might cause anxiety, if they are abusing alcohol or mood-altering drugs, if they are consuming large amounts of caffeine, or if their workplace is noisy or dangerous. In most cases, the most important source of diagnostic information is the patient's psychological and social history. The doctor may administer a brief psychological test to help evaluate the intensity of the patient's anxiety and some of its features. Some tests that are often given include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS). Many doctors will check a number of chemical factors in the blood, such as the level of thyroid hormone and blood sugar.

Treatment

Not all patients with anxiety require treatment, but for more severe cases, treatment is recommended. Because anxiety often has more than one cause and is experienced in highly individual ways, its treatment usually requires more than one type of therapy. In addition, there is no way to tell in advance how patients will respond to a specific drug or therapy. Sometimes the doctor will need to try different medications or methods of treatment before finding the best combination for the particular patient. It usually takes about six to eight weeks for the doctor to evaluate the effectiveness of a treatment regimen.

Medications

Medications are often prescribed to relieve the physical and psychological symptoms of anxiety. Most agents work by counteracting the biochemical and muscular changes involved in the fight-or-flight reaction. Some work directly on the chemicals in the brain that are thought to underlie the anxiety.

ANXIOLYTICS. Anxiolytics are sometimes called tranquilizers. Most anxiolytic drugs are either benzodiazepines or barbiturates. Barbiturates, once commonly used, are now rarely used in clinical practice. Barbiturates work by slowing down the transmission of nerve impulses from the brain to other parts of the body. They include such drugs as phenobarbital (Luminal) and pentobarbital (Nembutal). Benzodiazepines work by relaxing the skeletal muscles and calming the limbic system. They include such drugs as chlordiazepoxide (Librium) and diazepam (Valium). Both barbiturates and benzodiazepines are potentially habit-forming and may cause withdrawal symptoms, but benzodiazepines are far less likely than barbiturates to cause physical dependency. Both drugs also increase the effects of alcohol and should never be taken in combination with it.

Two other types of anxiolytic medications include meprobamate (Equanil), which is now rarely used, and buspirone (BuSpar), a new type of anxiolytic that appears to work by increasing the efficiency of the body's own emotion-regulating brain chemicals. Buspirone has several advantages over other anxiolytics. It does not cause dependence problems, does not interact with alcohol, and does not affect the patient's ability to drive or operate machinery. However, buspirone is not effective against certain types of anxiety, such as panic disorder.

ANTIDEPRESSANTS AND BETA-BLOCKERS. For some anxiety disorders, such as obsessive-compulsive disorder and panic type anxiety, a type of drugs used to treat depression, selective serotonin reuptake inhibitors (SSRIs; such as Prozac and Paxil), are the treatment of choice. A newer drug that has been shown as effective as Paxil is called escitalopram oxalate (Lexapro). Because anxiety often coexists with symptoms of depression, many doctors prescribe antidepressant medications for anxious/depressed patients. While SSRIs are more common, antidepressants are sometimes prescribed, including tricyclic antidepressants such as imipramine (Tofranil) or monoamine oxidase inhibitors (MAO inhibitors) such as phenelzine (Nardil).

Beta-blockers are medications that work by blocking the body's reaction to the stress hormones that are released during the fight-or-flight reaction. They include drugs like propranolol (Inderal) or atenolol (Tenormin). Beta-blockers are sometimes given to patients with post-traumatic anxiety symptoms. More commonly, the beta-blockers are given to patients with a mild form of social phobic anxiety, such as fear of public speaking.

Psychotherapy

Most patients with anxiety will be given some form of psychotherapy along with medications. Many patients benefit from insight-oriented therapies, which are designed to help them uncover unconscious conflicts and defense mechanisms in order to understand how their symptoms developed. Patients who are extremely anxious may benefit from supportive psychotherapy, which aims at symptom reduction rather than personality restructuring.

Two newer approaches that work well with anxious patients are cognitive-behavioral therapy (CBT), and relaxation training. In CBT, the patient is taught to identify the thoughts and situations that stimulate his or her anxiety, and to view them more realistically. In the behavioral part of the program, the patient is exposed to the anxiety-provoking object, situation, or internal stimulus (like a rapid heart beat) in gradual stages until he or she is desensitized to it. Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction. Both CBT and relaxation training can be used in group therapy as well as individual treatment. In addition to CBT, support groups are often helpful to anxious patients, because they provide a social network and lessen the embarrassment that often accompanies anxiety symptoms.

Psychosurgery

Surgery on the brain is very rarely recommended for patients with anxiety; however, some patients with severe cases of obsessive-compulsive disorder (OCD) have been helped by an operation on a part of the brain that is involved in OCD. Normally, this operation is attempted after all other treatments have failed.

Alternative treatment

Alternative treatments for anxiety cover a variety of approaches. Meditation and mindfulness training are thought beneficial to patients with phobias and panic disorder. Hydrotherapy is useful to some anxious patients because it promotes general relaxation of the nervous system. Yoga, aikido, t'ai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

Homeopathy and traditional Chinese medicine approach anxiety as a symptom of a systemic disorder. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Chinese medicine regards anxiety as a blockage of qi, or vital force, inside the patient's body that is most likely to affect the lung and large intestine meridian flow. The practitioner of Chinese medicine chooses acupuncture point locations and/or herbal therapy to move the qi and rebalance the entire system in relation to the lung and large intestine.

Prognosis

The prognosis for resolution of anxiety depends on the specific disorder and a wide variety of factors, including the patient's age, sex, general health, living situation, belief system, social support network, and responses to different anxiolytic medications and forms of therapy.

Prevention

Humans have significant control over thoughts, and, therefore, may learn ways of preventing anxiety by changing irrational ideas and beliefs. Humans also have some power over anxiety arising from social and environmental conditions. Other forms of anxiety, however, are built into the human organism and its life cycle, and cannot be prevented or eliminated.

Resources

PERIODICALS

"Lexapro Found to be as Effective as Paxil." Mental Health Weekly Digest (April 12, 2004): 16.

Masi, Gabriele, et al. "Generalized Anxiety Disorder in Referred Children and Adolescents." Journal of the American Academy of Child and Adolescent Psychiatry (June 2004): 752-761.

"Patients With Traumatic Bone Injuries Have Unrecognized Anxiety." Health & Medicine Week (June 28, 2004): 824.

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Anxiety Disorders

Anxiety Disorders

Anxiety disorders include separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, agoraphobia, panic disorder with and without agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder not otherwise specified. Common features shared across anxiety disorders include (1) avoidance of feared objects, situations, or events, or enduring such objects, situations, events with severe distress; (2) maladaptive thoughts or cognitions, typically regarding harm or injury to oneself or loved one; and (3) physiological arousal or reactions (e.g., palpitations, sweating, irritability). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994), with the exception of the anxiety disorder specific to childhood, separation anxiety disorder, the same criteria are applied for diagnosing anxiety disorders in adults and children. For all anxiety disorders, symptoms must be present for a specific time period (at least four weeks for separation anxiety disorder; six months for all other anxiety disorders), be age inappropriate, and interfere with an individual's functioning.


Ethnic and Cultural Variations

Epidemiological studies of anxiety disorders in children have rarely been conducted using diverse ethnic or racial groups. Hector R. Bird and his colleagues (1988) conducted a community study of behavioral and emotional problems in youth aged four to sixteen years in Puerto Rico. Prevalence rates for the most common anxiety disorders were 2.6 percent for specific phobia and 4.7 percent for separation anxiety disorder.

Glorisa Canino and her colleagues (1986) compared rates of anxiety symptoms (not diagnoses) in an outpatient clinic sample of African-American and Hispanic youth (aged five to fourteen years). Hispanic children were found to present with more symptoms of fears, phobias, anxiety, panic, school refusal, and disturbed peer relationships than African-American children. C. G. Last and S. Perrin (1993) compared African-American and Euro-American children (aged five to seventeen years) who were referred to a childhood anxiety disorders specialty clinic, and found no significant differences between the two groups in lifetime prevalence rates of anxiety diagnoses. Golda Ginsburg and Wendy Silverman's (1996) comparison of Hispanic and Euro-American children (aged six to seventeen years) who were referred to a childhood anxiety disorders specialty clinic indicated that the two groups were more similar than different on the main variables examined, including mean age at intake, family income, mean ratings of impairment of diagnoses (0-9 point scale), school refusal behavior, and number of co-occurring diagnoses. More research is needed on the expression of anxiety disorders using ethnically and culturally diverse samples of children.


Biological Factors

Evidence for biological factors that predispose children to anxiety disorders is based largely on findings from family aggregation, twin, behavioral genetic, and behavioral inhibition studies. Family aggregation studies suggest that children whose parents have an anxiety disorder are at risk for developing an anxiety disorder themselves (Biederman et al. 2001). Similarly, parents whose children have an anxiety disorder are likely to show anxiety disorders or symptoms themselves. Research on family aggregation also suggests that when parents have an anxiety disorder, mothers are more often associated with familial transmission of anxiety than fathers. Also, children of anxious parents are likely to have an earlier onset for anxiety disorders than their parents.

Twin studies also suggest a familial transmission. For example, concordance rates from different monozygotic (identical) and dizygotic (fraternal) twin pairs suggest a strong genetic basis for anxiety neurosis. Thalia C. Eley's (1999) review of behavioral genetic research concluded that factors in shared and nonshared environments of parents with anxiety disorders have an important influence on the development and maintenance of most anxiety disorders in their children and adolescents.

Recent research on behavioral inhibition and anxiety has provided important neurobiological insights regarding correlates in the etiology of anxiety disorders (Sallee and Greenawald 1995). Behavioral inhibition refers to the temperamental style of approximately 10 to 15 percent of Euro-American infants who are predisposed to being irritable, shy, and fearful as toddlers, and cautious, quiet, and introverted as school-aged children (e.g., Kagan 1989).

Although family, twin, behavioral genetic, and behavioral inhibition investigations all provide empirical support for biological dispositional factors in the etiology of anxiety disorders in children, the specific mechanism of transmission are unclear. This represents a critical area for further research.


Family Environment and Parenting Factors

Parenting styles of anxious children have been described as overprotecting, ambivalent, rejecting, and hostile (See Ginsburg, Silverman, and Kurtines 1995). Retrospective reports of adults with anxiety disorders show that these adults view their parents as overcontrolling and less affectionate. Studies of families of school-refusing/anxious children indicate that these families score lower on indices of child independence and participation in recreational activities, and higher on indices of hostility/conflict than families of non-school-refusing/anxious children (Kearney and Silverman 1995). These families also have been found to be more overprotective and disturbed in role performance, communication, affective expression, and control relative to families of children with nonanxiety psychiatric disorders (e.g., Bernstein and Garfinkel 1986). In a review of the parenting and child-rearing practices research literature, Ronald Rapee (1997) concluded that rejection and excessive parental control were related to the development and maintenance of anxiety disorders in children. An observational study conducted by Paula Barrett and her colleagues (1996) found that children with anxiety disorders and their parents generated more avoidant solutions in problem-solving situations relative to aggressive and nonclinical controls. These parents also modeled caution, provided information about risks, expressed doubts about child competency, and rewarded avoidant behavior. Moreover, having an anxious family member (e.g., parent) also has been shown to increase risk for distress and dysfunction in family relationships (Bruch and Heimberg 1994). Given the consistency of findings showing the role of the family environment and parenting factors, interventions have been aimed at incorporating these factors in treating children with anxiety disorders.


Family-Focused Interventions

Considerable evidence has accumulated demonstrating the efficacy of individual child cognitive behavior therapy (CBT) for reducing anxiety disorders in children (see Silverman and Berman 2001, for review). In consideration of the accumulating evidence (summarized above), highlighting the importance of the familial context in the development and maintenance of anxiety disorders, early twenty-first century clinical research was directed toward evaluating whether CBT, when used with anxious children, also is efficacious when family parenting variables are targeted in the treatment program. Such work also is a response to increasing interest among practitioners in having available alternative treatment approaches that draw on supplementary therapeutic resources, especially when individual child therapy does not seem sufficient.

As a result, empirical evidence from clinical trials as well as single case study designs suggests that childhood anxiety disorders can be reduced when exposure-based cognitive behavioral treatments target family/parent variables. For example, in a sample of seventy-nine children (ages seven to fourteen years old) and their parents, Paula Barrett, Mark Dadds, and Ronald Rapee (1996) demonstrated that individual cognitive behavioral treatment (ICBT) might be enhanced by parental involvement in the treatment of childhood anxiety disorders when compared to a wait-list comparison group. Results indicated that a large percentage (69.8%) of children who received ICBT, either with or without a parenting component, no longer met diagnostic criteria for an anxiety disorder. Moreover, children who received ICBT with a parenting component had significantly higher treatment success rates (84%) than children who received ICBT without the parenting component (57.1%). Improvement also was evident on child and parent rating scales, though statistically significant differences between the treatment conditions (i.e., ICBT with parent involvement vs. ICBT without parent involvement) were not as apparent on these measures. An interesting age/treatment interaction was observed in that younger children showed more improvement in ICBT with the parenting component than older children who received ICBT without the parenting component.

Barrett and colleagues (2001) reported long-term (five to seven years post-treatment) maintenance of treatment gains from Barrett, Dadds, and Rapee's (1996) study. For both treatment conditions (i.e., ICBT with parental involvement vs. ICBT without parental involvement), treatment gains were maintained for this period as shown by continued absence of the targeted anxiety disorder diagnosis as reported by the child, and on all the child and parent rating scales. The only exception was levels of self-rated fear: children who received ICBT with parental involvement rated significantly less fear at long-term follow-up in comparison to children who received ICBT without parental involvement.

Findings from Vanessa Cobham, Mark Dadds, and Susan Spence (1998) provide additional evidence for ICBT as well as for the involvement of parents in intervention. In this study parental involvement included not only parental management of the child's anxiety, but also parental management of their own anxiety. Children (N=67; ages seven to fourteen years old) with anxiety disorders were assigned to conditions according to whether parents were anxious or not. Treatment success rates for ICBT among children with nonanxious parents were similar to those children with anxious parents who received ICBT plus a parental anxiety management component. Thus, the addition of a parent anxiety management component to ICBT was important for diagnostic recovery for those children with anxious parents.

Barrett (1998) evaluated the effectiveness of including a family component to group CBT. Participants consisted of sixty children (ages seven to fourteen years old) and their parents. Treatment conditions were: (1) child group CBT, (2) child group CBT plus a family management component, and (3) a wait-list control condition. The family management component consisted of parent training of contingency management techniques for their child's anxiety and for any anxiety that parents may experience themselves. Results indicated that children in both group CBT and group CBT plus the family component showed positive treatment in comparison to the wait-list condition. However, children in the group CBT plus family component condition showed somewhat better improvement than children in the group CBT condition as evident in less family disruption, greater parental perception of ability to deal with child's behaviors, and lower child's reports of fear. At one-year follow-up, children in the group CBT plus family maintained lower scores for internalizing and externalizing behaviors as reported by parents. Overall, however, both treatment conditions produced significant change in terms of successful treatment outcome relative to the waitlist condition.

Sandra Mendlowitz and colleagues (1999) conducted a clinical trial examining group CBT for anxiety in children (N=68; ages seven to twelve years old). Three conditions were compared: (1) group CBT for children only, (2) group CBT for children and parents, and (3) group CBT for parents only. A wait-list control condition also was included. Improvement was noted for all treatment conditions in terms of reduction in anxiety symptoms; however, children in the group CBT for children and parents condition showed significantly greater improvement in their coping strategies relative to children in the other conditions.

Susan Spence, Caroline Donovan, and Margaret Brechman-Toussaint (2000) conducted a clinical trial for children with social phobia (N=50; ages seven to fourteen years old) in which group CBT was compared to group CBT with parental involvement, and a wait-list control. Parental involvement consisted mainly of enhanced contingency management techniques taught to parents during therapy sessions. Results indicated that both treatment conditions (i.e., ICBT and ICBT with the parental component) showed significant improvements at post-treatment and twelve-month follow-up when compared to the wait-list condition. It is interesting, however, that comparisons between the two treatment conditions did not show statistically significant differences, suggesting both conditions were efficacious in reducing symptoms of social phobia.

Two late-twentieth-century studies reported on parent and family factors that may be related to treatment success or failure (Berman et al. 2000). Steven L. Berman and his colleagues (2000) found that child symptoms of depression as well as parent self-reported symptoms of depression, fear, hostility, and/or paranoia were predictive of treatment failure. Melissa Crawford and Katharina Manassis (2001) found that child, maternal, and paternal reports of family dysfunction and maternal frustration were significant predictors of a less favorable outcome in child's anxiety and overall functioning. Also, paternal reports of multiple physiological symptoms for which no medical cause was evident were predictive of a less favorable outcome in terms of overall child functioning.

In sum, there is strong and consistent evidence showing a familial influence in the development and maintenance of anxiety disorders. This evidence supports both a biological and psychosocial influence. The intervention research literature further suggests strong evidence for the efficacy of ICBT for reducing anxiety disorders in children. Although the effects might be enhanced when including a family component to the intervention, further research on this issue is needed.


See also:Attachment: Parent-Child Relationships; Chronic Illness; Codependency; Developmental Psychopathology; Disabilities; Parenting Styles; Posttraumatic Stress Disorder (PTSD); School Phobia and School Refusal; Separation Anxiety; Shyness; Substitute Caregivers; Therapy: Couple Relationships


Bibliography

american psychiatric association. (1994). diagnostic andstatistical manual of mental disorders, 4th edition. washington, dc: author.

barrett, p. m.; dadds, m. r.; and rapee, r. m. (1996)."family treatment of childhood anxiety: a controlled trial." journal of consulting and clinical psychology 64:333–342.

barrett, p. m.; duffy, a. l.; dadds, m. r.; and rapee r. m.(2001). "cognitive-behavioral treatment of anxietydisorders in children: long-term (6-year) follow-up." journal of consulting and clinical psychology 69:135–141.

berman, s. l.; weems, c. f.; silverman, w. k.; andkurtines, w. m. (2000). "predictors of outcome in exposure-based cognitive and behavioral treatments for phobic and anxiety disorders in children." behavior therapy 31:713–731.

bernstein, g. a., and garfinkel, b. d. (1986). "schoolphobia: the overlap of affective and anxiety disorders." journal of the american academy of child and adolescent psychiatry 25:235–241.

biederman, j.; rosenbaum, j. f.; hirshfeld, d. r.; andfaraone, s. v. (1990). "psychiatric correlates of behavioral inhibition in young children of parents with and without psychiatric disorders." archives of general psychiatry 47:21–26.

biederman, j.; faraone, s. v.; hirshfeld-becker, d. r.;friedman, d.; robin, j. a.; and rosenbaum, j. f. (2001). "patterns of psychopathology and dysfunction in high-risk children of parents with panic disorder." american journal of psychiatry 158:49–57.

bird, h. r.; canino, g.; rubio-stipec, m.; and gould, m. s. (1988). "estimates of the prevalence of childhood maladjustment in a community survey in puerto rico: the use of combined measures." archives of general psychiatry 45:1120–1126.

bruch, m. a., and heimberg, r. g. (1994). "differences inperceptions of parental and personal characteristics between generalized and nongeneralized social phobics." journal of anxiety disorders 8:155–168.

canino, i. a.; gould, m. a.; prupis, s.; and schaffer d.(1986). "a comparison of symptoms and diagnoses in hispanic and black children in an outpatient mental health clinic." journal of the american academy of child psychiatry 25:254–259.

cobham, v. e.; dadds, m. r.; and spence, s. h. (1998)."the role of parental anxiety in the treatment of childhood anxiety." journal of consulting and clinical psychology 66:893–905.

eley, t. (1999). "behavioral genetics as a tool for developmental psychology: anxiety and depression in children and adolescents." clinical child and family psychology review 2:21–36.

ginsburg, g. s., and silverman, w. k. (1996). "phobic andanxiety disorders in hispanic and caucasian youth." journal of anxiety disorders 10:517–528.

ginsburg, g. s.; silverman, w. k.; and kurtines, w. k.(1995). "family involvement in treating children withphobic and anxiety disorders: a look ahead." clinical psychology review 15: 457–473.

kagan, j. (1989). "temperamental contributions to socialbehavior." american psychologist 44:668–674.

kearney, c. a., and silverman, w. k. (1995). "family environment of youngsters with school refusal behavior: a synopsis with implications for assessment and treatment." american journal of family therapy 23:59–72.

last, c. g., and perrin, s. (1993). "anxiety disorders inafrican-american and white children." journal of abnormal child psychology 21:153–164.

mendlowitz, s. l.; manassis, k.; bradley, s.; scapillato, d.;miezitis, s.; and shaw, b. f. (1999). "cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement." journal of the american academy of child and adolescent psychiatry 38:1223–1229.

rapee, r. (1997). "potential role of childrearing practices in the development of anxiety and depression." clinical psychology review 17:47–67.

sallee, r., and greenawald, j. (1995). "neurobiology." inanxiety disorders in children and adolescents, ed. j. s. march. new york: guilford press.

silverman, w. k., and berman, s. l. (2001). "psychosocialinterventions for anxiety disorders in children: status and future directions." in anxiety disorders in children and adolescents: research, assessment and intervention, ed. w. k. silverman and p. d. a. treffers. cambridge, uk: cambridge university press.

spence, s. h.; donovan, c.; and brechman-toussaint, m.(2000). "the treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitive behavioural intervention, with and without parent involvement." journal of child psychology and psychiatry and allied disciplines 41:713–726.

lissette m. saavedrawendy k. silverman

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"Anxiety Disorders." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

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Anxiety

Anxiety

Definition

Anxiety is a bodily response to a perceived threat or danger. It is triggered by a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation.

It is important to distinguish between anxiety as a feeling or experience and an anxiety disorder as a psychiatric diagnosis. A person may feel anxious without having an anxiety disorder. Also, a person facing a clear and present danger or a realistic fear is not usually considered to be in a state of anxiety. In addition, anxiety frequently occurs as a symptom in other categories of psychiatric disturbance.

Description

Anxiety is related to fear, but it is not the same thing. Fear is a direct, focused response to a specific event or object of which an individual is consciously aware. Most people will feel fear if someone points a loaded gun at them or if they see a tornado forming on the horizon. They also will recognize that they are afraid. Anxiety, on the other hand, is often unfocused, vague, and hard to pin down to a specific cause.

Sometimes anxiety experienced in the present may stem from an event or person that produced pain and fear in the past. In this experience, the anxious individual may not be consciously aware of the original source of the feeling. Anxiety has an aspect of remoteness that makes it hard for people to compare their experiences. Whereas most people will be fearful in physically dangerous situations, and can agree that fear is an appropriate response in the presence of danger, anxiety is often triggered by objects or events that are unique and specific to an individual. An individual might be anxious because of a unique meaning or memory being stimulated by present circumstances, not because of some immediate danger.

Causes & symptoms

Anxiety is characterized by the following symptoms:

  • Somatic. These physical symptoms include headaches, dizziness or lightheadedness, nausea and/or vomiting, diarrhea , tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands. These symptoms are produced by the hormonal, muscular, and cardiovascular reactions involved in the fight-or-flight reaction.
  • Behavioral. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, and finger tapping.
  • Cognitive. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion or inability to concentrate.
  • Emotional. Emotional symptoms include feelings of tension or nervousness, feeling "hyper" or "keyed up," and feelings of unreality, panic, or terror.

Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person's environment, or a response to an internal stimulus (for example, a hypochondriac's reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.

Physical triggers

In some cases, anxiety is produced by physical responses to stress or by certain disease processes or medications.

THE AUTONOMIC NERVOUS SYSTEM (ANS). The nervous system of human beings is hard-wired to respond to dangers or threats. These responses are not subject to conscious control and are the same in humans as in lower animals. They represent an evolutionary adaptation to animal predators and other dangers that all animalsincluding primitive humanshad to cope with.

The most familiar reaction of this type is the fight-or-flight reaction to a life-threatening situation. When people have fight-or-flight reactions, the level of stress hormones in their blood rises. They become more alert and attentive, their eyes dilate, their heartbeats increase, their breathing rates increase, and their digestion slows down, making more energy available to the muscles.

This emergency reaction is regulated by a part of the nervous system called the autonomic nervous system, or ANS. The ANS is controlled by the hypothalamus, a specialized part of the brainstem that is among a group of structures called the limbic system. The limbic system controls human emotions through its connections to glands and muscles; it also connects to the ANS and higher brain centers, such as parts of the cerebral cortex.

One problem with this arrangement is that the limbic system cannot tell the difference between a real physical threat and an anxiety-producing thought or idea. The hypothalamus may trigger the release of stress hormones from the pituitary gland even when there is no external danger.

A second problem is caused by the biochemical side effects of too many false alarms in the ANS. When a person responds to a real danger, his or her body relieves itself of the stress hormones by facing up to the danger or fleeing from it. In modern life, however, people often have fight-or-flight reactions in situations where they can neither run away nor lash out physically. As a result, their bodies have to absorb all the biochemical changes of hyperarousal rather than release them. These biochemical changes can produce anxious feelings as well as muscle tension and other physical symptoms of anxiety.

DISEASES AND DISORDERS. Anxiety can be a symptom of certain medical conditions. For example, anxiety is a symptom of certain endocrine disorders that are characterized by over activity or under activity of the thyroid gland. Cushing's syndrome, in which the adrenal cortex overproduces cortisol, is one such disorder. Other medical conditions that can produce anxiety include respiratory distress syndrome, mitral valve prolapse, porphyria, and chest pain caused by inadequate blood supply to the heart (angina pectoris).

MEDICATIONS AND SUBSTANCE USE. Numerous medications may cause anxiety-like symptoms as a side effect. They include birth control pills, some thyroid or asthma drugs, some psychotropic agents, corticosteroids, antihypertensive drugs, nonsteroidal anti-inflammatory drugs (such as flurbiprofen and ibuprofen), and local anesthetics. Caffeine can also cause anxiety-like symptoms when consumed in sufficient quantity.

Withdrawal from certain prescription drugsprimarily beta-blockers and corticosteroidscan cause anxiety. Withdrawal from drugs of abuse, including LSD, cocaine, alcohol, and opiates, can also cause anxiety.

Childhood development and anxiety

Researchers in early childhood development regard anxiety in adult life as a residue of childhood memories of dependency. Humans learn during the first year of life that they are not self-sufficient and that their basic survival depends on others. It is thought that this early experience of helplessness underlies the most common anxieties of adult life, including fear of powerlessness and fear of not being loved. Thus, adults can be made anxious by symbolic threats to their sense of competence or significant relationships, even though they are no longer helpless children.

Symbolization

The psychoanalytic model gives a lot of weight to the symbolic aspect of human anxiety; examples include phobic disorders, obsessions, compulsions, and other forms of anxiety that are highly individualized. Because humans mature slowly, children and adolescents have many opportunities to connect their negative experiences to specific objects or events that can trigger anxious feelings in later life. For example, a person who was frightened as a child by a tall man wearing glasses may feel panicky years later, without consciously knowing why, by something that reminds him of that person or experience.

Freud thought that anxiety results from a person's internal conflicts. According to his theory, people feel anxious when they feel torn between moral restrictions and desires or urges toward certain actions. In some cases, the person's anxiety may attach itself to an object that represents the inner conflict. For example, someone who feels anxious around money may be pulled between a desire to steal and the belief that stealing is wrong. Money becomes a symbol for the inner conflict between doing what is considered right and doing what one wants.

Phobias

Phobias are a special type of anxiety reaction in which the person concentrates his or her anxiety on a specific object or situation and then tries to avoid. In most cases, the person's fear is out of proportion to its "cause." It is estimated that 1011% of the population will develop a phobia in their lifetime. Some phobiasagoraphobia (fear of open spaces), claustrophobia (fear of small or confined spaces), and social phobia, for exampleare shared by large numbers of people. Others are less common or are unique to the patient.

Social and environmental stressors

Because humans are social creatures, anxiety often has a social dimension. People frequently report feelings of high anxiety when they anticipate or fear the loss of social approval or love. Social phobia is a specific anxiety disorder that is marked by high levels of anxiety or fear of embarrassment in social situations.

Another social stressor is prejudice. People who belong to groups that are targets of bias have a higher risk of developing anxiety disorders. Some experts think, for example, that the higher rates of phobias and panic disorder among women reflects their greater social and economic vulnerability.

Several controversial studies indicate that the increase in violent or upsetting pictures and stories in news reports and entertainment may raise people's anxiety levels. Stress and anxiety management programs often recommend that patients cut down their exposure to upsetting stimuli.

Environmental or occupational factors can also cause anxiety. People who must live or work around sudden or loud noises, bright or flashing lights, chemical vapors, or similar nuisances that they cannot avoid or control may develop heightened anxiety levels.

Diagnosis

Diagnosing anxiety is difficult and complex because of the variety of possible causes and because each person's symptoms arise from highly personalized and individualized experiences. When a doctor examines an anxious patient, he or she will first rule out physical conditions and diseases that have anxiety as a symptom. The doctor will then take the patient's history to see if prescription drugs, alcohol or drug abuse, caffeine, work environment, or other external stressors could be triggering the anxiety. In most cases, the most important source of diagnostic information is the patient's psychological and social history. The doctor may administer several brief psychological tests, including the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).

Treatment

Meditation and mindfulness training can benefit patients with phobias and panic disorder. Hydrotherapy, massage therapy , and aromatherapy are useful to some anxious patients because they can promote general relaxation of the nervous system. Essential oils of lavender, chamomile , neroli, sweet marjoram, and ylang-ylang are commonly recommended by aromatherapists for stress relief and anxiety reduction.

Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction. Yoga , aikido, tai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

Homeopathy and traditional Chinese medicine (TCM) approach anxiety as a symptom of a holistic imbalance. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Homeopathic remedies for anxiety include ignatia, gelsemium, aconite, pulsatilla, arsenicum album , and coffea cruda. These remedies should be prescribed by a homeopathic healthcare professional.

Chinese medicine regards anxiety as a disruption of qi, or energy flow, inside the patient's body. Acupuncture and/or herbal therapy are standard remedies for rebalancing the entire system. Reishi (Ganoderma lucidum or Ling-Zhi) is a medicinal mushroom prescribed in TCM to reduce anxiety and insomnia . However, because reishi can interact with other prescription drugs and is not recommended for patients with certain medical conditions, individuals should consult their healthcare practitioner before taking the remedy. Other TCM herbal remedies for anxiety include the cordyceps mushroom (also known as catepillar fungus) and Chinese green tea . In addition, there are numerous TCM formulas that combine multiple herbs for use as an anxiety treatment, depending on the individual problem.

Herbs known as adaptogens may also be prescribed by herbalists or holistic healthcare providers to treat anxiety. These herbs are thought to promote adaptability to stress, and include Siberian ginseng (Eleutherococcus senticosus ), ginseng (Panax ginseng ), wild yam (Dioscorea villosa ), borage (Borago officinalis ), licorice (Glycyrrhiza glabra ), chamomile (Chamaemelum nobile ), milk thistle (Silybum marianum ), and nettles (Urtica dioica ). Tonics of skullcap (Scutellaria lateriafolia ), and oats (Avena sativa ), may also be recommended to ease anxiety.

A 2002 preliminary study found that St. John's wort could be an effective treatment for generalized anxiety. Patients taking 900 mg a day and higher doses responded well in early trials. However, further research was needed, particularly at doses higher than 900 mg per day. The Ayurvedic herb gotu kola , long used by practitioners of India's holistic medical system to enhance memory and relieve varicose veins , may also help patients with anxiety by working against the startle response.

Allopathic treatment

Because anxiety often has more than one cause and is experienced in highly individual ways, its treatment often requires more than one type of therapy. In some cases, several types of treatment may need to be tried before the best combination is discovered. It usually takes about six to eight weeks to evaluate the effectiveness of a treatment regimen.

Medications

Medications are often prescribed to relieve the physical and psychological symptoms of anxiety. Most medications work by counteracting the biochemical and muscular changes involved in the fight-or-flight reaction. Some work directly on the brain chemicals that are thought to underlie the anxiety.

ANXIOLYTICS. Anxiolytics are sometimes called tranquilizers. Most anxiolytic drugs are either benzodiazepines or barbiturates. However, barbiturates, once commonly used, are now rarely used in clinical practice. Benzodiazepines work by relaxing the skeletal muscles and calming the limbic system. They include such drugs as chlordiazepoxide (Librium) and diazepam (Valium). Both barbiturates and benzodiazepines are potentially habit-forming and may cause withdrawal symptoms, but benzodiazepines are far less likely than barbiturates to cause physical dependency.

Two other types of anxiolytic medications include meprobamate (Equanil), which is now rarely used, and buspirone (BuSpar), a new type of anxiolytic that appears to work by increasing the efficiency of the body's own emotion-regulating brain chemicals. Unlike barbiturates and benzodiazepines, buspirone does not cause dependence problems, does not interact with alcohol, and does not affect the patient's ability to drive or operate machinery. However, buspirone is not effective against certain types of anxiety, such as panic disorder.

ANTIDEPRESSANTS AND BETA-BLOCKERS. The treatment of choice for obsessive-compulsive disorder , panic type anxiety, and other anxiety disorders is a group of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Paxil. When anxiety occurs in tandem with depressive symptoms, tricyclic antidepressants such as imipramine (Tofranil) or monoamine oxidase inhibitors (MAO inhibitors) such as phenelzine (Nardil) are sometimes prescribed.

Beta-blockers are medications that work by blocking the body's reaction to the stress hormones that are released during the fight-or-flight reaction. They include drugs like propranolol (Inderal) or atenolol (Tenormin). Beta-blockers are sometimes given to patients with post-traumatic anxiety symptoms or social phobic anxiety.

Psychotherapy

Most patients with anxiety will be given some form of psychotherapy along with medication. Many patients benefit from insight-oriented therapies, which are designed to help them uncover unconscious conflicts and defense mechanisms in order to understand how their symptoms developed.

Cognitive-behavioral therapy (CBT) also works well with anxious patients. In CBT, the patient is taught to identify thoughts and situations that stimulate his or her anxiety, and to view them more realistically. In the behavioral part of the program, the patient is exposed to the anxiety-provoking object, situation, or internal stimulus (like a rapid heart beat) in gradual stages until he or she is desensitized to it.

Expected results

Unfortunately, a 2002 report stated that about half of the patients with an anxiety disorder who see their primary care physician go untreated. The prognosis for resolving anxiety depends on the specific disorder and a wide variety of factors, including the patient's age, general health, living situation, belief system, social support network, and responses to different medications and forms of therapy.

Resources

BOOKS

"Anxiety Disorders." In Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: The American Psychiatric Association, 1994.

Bloomfield, Harold H. Healing Anxiety with Herbs. New York: HarperCollins, 1998.

Corbman, Gene R. "Anxiety Disorders." In Current Diagnosis 9, edited by Rex B. Conn, et al. Philadelphia: W. B. Saunders, 1997.

PERIODICALS

Gaby, Alan R. "Consider St. John's Wort as Alternative to Kava. (Literature Review & Commentary)." Townsend Letter for Doctors and Patients (May 2002):34.

Mandile, Maria Noel. "Gotu Kola: This Ayurvedic Herb May Reduce Your Anxiety Without the Side Effects of Drugs." Natural Health (MayJune 2002):34.

Zoler, Michael L. "Anxiety Disorder Often Goes Untreated in Primary Care. (504 Patients in 15 Practices Studied)." Family Practice News (April 1, 2002):14 21.

ORGANIZATION

The American Botanical Council. P.O. Box 144345, Austin, Texas 78714-4345. (512) 926-4900. Fax: (512) 926-2345. http://www.herbalgram.org.

Paula Ford-Martin

Teresa G. Odle

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Ford-Martin, Paula; Odle, Teresa. "Anxiety." Gale Encyclopedia of Alternative Medicine. 2005. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula; Odle, Teresa. "Anxiety." Gale Encyclopedia of Alternative Medicine. 2005. Encyclopedia.com. (July 26, 2016). http://www.encyclopedia.com/doc/1G2-3435100044.html

Ford-Martin, Paula; Odle, Teresa. "Anxiety." Gale Encyclopedia of Alternative Medicine. 2005. Retrieved July 26, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435100044.html

Anxiety

ANXIETY

Anxiety is an unpleasurable affect in which the individual experiences a feeling of danger whose cause is unconscious. Freud had already begun considering the problem of anxiety in his correspondence with Wilhelm Fliess at the very start of his psychoanalytic work (1950a [1887-1902]). His subsequent efforts were more and more systematic as he developed two successive theories of anxiety.

In both of Freud's theories of anxiety a fundamental role is played by an absence of discharge, and hence of instinctual satisfaction. In his first account, the sexual instinct, undischarged, was described as being transformed explicitly into anxiety by a seemingly biological mechanism (1895b [1894]). Somatic sexual excitation with the help of sexual ideas thus could not develop into psychic libido. However, sexual representations could be repressed, and their attendant excitation either diverted toward somatic outlets, so giving rise to hysterical conversion symptoms or, alternatively, redirected into the substitute representations typical of anxiety hysteria or phobic neurosis.

In Freud's second theory of anxiety, set forth in Inhibitions, Symptoms, and Anxiety (1926d [1925]), unsatisfied instincts were not explicitly evoked. In this account, anxiety as a signal is developed by the ego as a defensive measure against automatic anxiety. The infant's biological and mental immaturity does not enable it to confront the increase in tension arising from the enormous amounts of instinctual excitation that it cannot discharge and satisfy. This generates a state of distress that is traumatic for the newborn, triggering automatic anxiety. The infant gradually comes to understand that the maternal object can put an end to this state of affairs. It is then that the loss of the mother is experienced as a danger, and this experience constitutes anxiety as a signal.

When the newborn begins to perceive its mother, it is unable to distinguish temporary absence from enduring loss; thus from the moment the mother is lost sight of, the baby behaves as if it is never going to see her again. Repeated experiences of satisfaction have created this object, the mother, which, as need arises, is intensely cathected in a way that might be described as nostalgic. From this moment on, in Freud's view, object-loss provokes psychic pain, while anxiety is the reaction to the danger associated with that loss. Sadness arises whenever reality-testing forces an acknowledgment that the object has been lost. In its various forms, object-loss becomes the prototype of later anxieties, which Freud lists as: anxiety at the loss of the love of the object, castration anxiety, and anxiety at the loss of the love of the superego.

The novelty of this theorization derives, on the one hand, from the genetic notion according to which anxiety is tied to the fear of re-experiencing very early human states of distress, and on the other hand, from the fact that these states are associated during early infancy with various fantasies about the maternal object, and later with fantasies concerning other objects, including the father (castration anxiety or anxiety at the loss of the love of the superego). The close connection thus posited between anxiety and ideation is radically at odds with Freud's first theory of anxiety.

Anxiety always occupied a central place in the work of Melanie Klein, first of all with respect to technique, and secondly in terms of theory. She stated repeatedly that her chief technical principle was that interpretation must focus on the point of maximum anxiety. Equilibrium between the life instincts and the death instincts was fundamental to Klein's understanding of the different forms of anxiety and the fantasies that expressed them. In her earliest writings, she associated anxiety and its related inhibitions with sexual conflicts of childhood bound up with the Oedipus complex. At the same time, however, she was struck by the scope of aggressive fantasies in young children, especially during what she called the phase of maximal sadism. She gradually came to view the child's aggressiveness towards the mother's body and its fantasy contents (penis, baby, feces, etc.) as responsible for an anxiety based on the fear of the reciprocal aggression it could provoke. The danger intrinsic to anxiety was thus seen as the result of the subject's excessive aggressiveness.

Although to begin with Klein's theory leaned heavily on Freud's Inhibitions, Symptoms, and Anxiety, from 1935 on, and especially after 1940, with the gradual working out of the concept of the "depressive position," she assigned object-loss a central role. This implied a change in the conceptualization of anxiety, which acquired a depressive character: anxiety was now seen as expressing "pain," which for Klein included both suffering and sadness in Freud's sense. Anxiety states were engendered by lived experiences of object-loss that were more or less definitive and irreversible.

Since experiences of loss were closely associated with the damage wreaked in fantasy by aggressive impulses, painful feelings were accompanied by feelings of conscious or unconscious guilt. This guilt generally tended to remain unconscious because of the great importance it assumed for the subject, who attributed an all-powerful destructiveness to his own aggression. The ego would then turn to radical (psychotic, manic, or depressive) defenses, which also made it difficult for painful feelings to gain access to consciousness. On the other hand, the more real the guilt, the more vigorously it would be supported by the ego, clearing a path to consciousness by way of feelings of sadness. A basic exception to this rule were the strong guilt feelings manifested by melancholics, whose self-reproach masked an attempt by the ego to overwhelm the introjected and attacked object with guilt.

After introducing the "paranoid-schizoid position" (1946), which she contrasted with the depressive position as a type of psychic functioning, Melanie Klein was able to develop a systematic theory of anxiety and guilt (1948). The theory relied primarily on Freud's concept of the death instinct, which Klein had adopted. In this view, anxiety was provoked by the danger with which the death instinct threatened the organism. Klein spoke of anxiety about "annihilation" and "fragmentation" with reference to very primitive terrors triggered by the inner working of the death instinct and with reference to the paranoid anxiety generated by persecutory objects or by the primitive superego. In this sense fragmentation anxiety may be considered a very archaic precursor of castration anxiety.

In the face of maternal frustration, Klein contended, the sense of an internal threat created by the death instinct reinforces the projection of destructive impulses by the primitive ego of the paranoid-schizoid position. As a consequence the breast as "bad" part-object becomes the source of "paranoid" or persecutory anxiety. Another portion of the death instinct is used by the ego in the form of aggression to attack the persecutory object. Introjection of both the persecutory breast and the persecutory penis is the foundation of the primitive superego, which is at first difficult to distinguish from internal persecutory objects since it provokes very intense persecutory anxiety (fear of fragmentation). This very early superego, in spite of its aggressiveness, strives to protect the libidinal bonds that the ego is meanwhile forming with good or idealized objects, which are experienced as the source of life.

As progress is made, with the help of libidinal instincts, toward the successful integration of aggression, fantasies arise, characteristic of the early stages of the Oedipus complex, involving part-objects in the process of being made whole: the mother's stomach and its fantasized contents (penis, baby, feces, etc.). If such objects provoke psychotic persecutory anxieties, these will manifest themselves clinically as the outcome of a defensive transformation of intolerable depressive anxieties produced under pressure from an overly aggressive primitive superego. In fact, as Klein indicated in her last writings, the paranoid-schizoid and depressive positions act simultaneously, whether in the service of defense or of integration. In clinical work, this is reflected in the coexistence of paranoid and depressive anxieties; one or the other will prevail, depending on which position is predominant in the patient.

During the various steps in the integration of the depressive position, a whole range of depressive anxieties is encountered, as distinguished by the particular fantasies that attend the loss of the libidinally cathected object in each type of case (Palacio Espasa, 1993). Thus whenever fantasies of catastrophic destruction come to the fore and the damage is experienced by the subject as irreparable because of the great force of his aggression, as he perceives it, the intensity of the ensuing guilt makes the pain and sadness hard to bear. The ego can only resort to psychotic defenses that transform these disastrous depressive anxieties into persecutory anxieties.

Where fantasies of destruction are less significant, and the subject's aggressiveness is experienced as less destructive, fantasies of the death of libidinally cathected objects may be prevalent. The ego can then use its store of libido, which it experiences as limited, as a massive barrier to any manifestation of aggression. This arouses intense feelings of guilt, and hence of responsibility for fears of death or of object-loss. The ego tends to defend itself against such painful depressive affects either in manic fashion, through identification with idealized and intact objects, or else by melancholic means, such as identification with the dead or destroyed aspects of objects.

When fantasies of loss of the object's love predominate, they center on rejection or abandonment by the object. Death fantasies are less intense and are experienced as more easily reversible because of the greater libidinal capacity available to the ego of subjects in this category. Under these circumstances the ego has a whole panoply of neurotic defenses at its disposal. These include the retroactive denial of the ill consequences of the subject's aggression and reaction-formations against aggression of a typically obsessive-neurotic kind. By means of phobic displacement and symbolization, a predominance of libidinal impulses facilitates the transformation of the conflict provoked by the loss of the object's love into a triangular conflict in which fantasies of exclusion become more prominent. Given well-integrated instinctual relationships with two highly cathected parental imagos, the experienced object-loss may be reduced to that of the loss of the incestuous object's exclusive love. On the other hand, the dangerous aggressiveness deemed responsible for the loss of the object's love may be projected onto the other parent, who then becomes a rival. An oedipal situation is thus created, along with the various conflicts, directly or indirectly expressed, that characterize the Oedipus complex.

In short, as the intensity of depressive anxieties decreases, the Oedipus complex comes to the fore thanks to the transformation of depressive conflict into a variety of neurotic conflicts that generate castration anxiety. In neurosis, however, along with castration anxiety intense depressive anxieties (especially guilt) may continue to exist with respect to the oedipal parentsmore complete objects, often neglected in the literature on neurosis. Such anxieties may indeed occasion significant regression back toward depressive conflict.

In psychoanalytic theory castration anxiety is closely bound up with the Oedipus complex. For Freud castration is one of the primal fantasies. In his view of childhood sexuality, the Oedipus complex makes its appearance during the stage of phallic primacy, which means that castration anxiety is rather similar in the two sexes. Because of the overvaluation of the phallus, the child does not recognize the female sex as such and considers it to be the result of castration. In Inhibitions, Symptoms, and Anxiety Freud sees castration as one loss, on the level of genital sexuality, in a series of object-losses: the loss of the mother's breast, the loss of the contents of the intestines, and so on.

For Melanie Klein castration anxiety develops as a fear of reprisal for the child's oedipal rivalry with the parent of the same sex. In boys this becomes an anxiety about the loss of the penis at the hands of a vengeful father; in girls it becomes an anxiety about attacks against her own belly by the persecuting maternal object. From this theoretical standpoint, castration anxiety appears as a form of punishment for the manic and narcissistic fantasies constructed by the young child as protection against its feelings of exclusion from the sexual and genital relations of the parents, to which it does not have access because of its biological immaturity. The infant then takes possession in fantasy of the idealized sexual attributes of the parent of the same sex, who thus becomes a rival, and imagines it is the exclusive recipient of the love of the parent of the opposite sex. Such a fantasy position can only generate castration anxiety, if for no other reason than that it derives from the infant's apprehension of its own biological immaturity as a mutilation.

Separation anxiety appears when the subject experiences separation as a more or less irreversible object-loss. In the descriptions given by Margaret Mahler, the very young infant manifests separation anxieties after the fifth or sixth month, and they become especially significant between 15 and 18 months of age, during the rapprochement subphase of the separation-individuation (Mahler et al.). During this time the baby experiences real despair, feelings close to the nascent melancholy that Klein describes as occurring at the height of the depressive position. The presence of the external mother is essential, for her internal image is experienced as very much under threat from the child's aggressive fantasies, perceived by the child as massive and highly destructive. Only after the age of two or three, during the phase of object constancy, does the child become able little by little to overcome separation anxiety; by then it can retain an inner mental representation of the mother that is cathected for the most part by libidinal impulses.

Anxiety in the presence of actual danger, or "realistic anxiety," is a somewhat paradoxical concept employed by Freud in Inhibitions, Symptoms, and Anxiety, where (as we have seen) he views anxiety as arising from a felt danger from within occasioned by object-loss. Freud himself resolves the ambiguity when he asserts, in discussing apparently external dangers such as the loss of the object's love, or castration anxiety, that "the loved person would not care to love us nor should we be threatened with castration if we did not entertain certain feelings and intentions within us. Thus such instinctual impulses are determinants of external dangers and so become dangerous in themselves" (p. 145). In other words, all realistic anxiety is also anxiety tout court, and not simply fear of an external danger, for it always arouses an internal threat. This idea is crucial, of course, to the Kleinian concept of the depressive position, where every outside loss is accompanied by an experience of the loss of internal objects. Primitive experiences of loss are reactivated by the real loss, so that the working-through of such early internal losses is a prerequisite if objects lost in the outside world are to be successfully mourned.

Francisco Palacio Espasa

See also: Abandonment; Annihilation anxiety; Anxiety dream; Aphanisis; Claustrophobia; Counterphobic; Defense; Ego; Fear; Hypochondria; Hysteria; Inhibitions, Symptoms, and Anxiety ; "Neurasthenia and Anxiety Neurosis"; Nervous Anxiety States and their Treatment ; Nightmare; Paranoid-schizoid position; Phobias in children; Primitive agony; Quota of affect; Seminar, Lacan's; Signal anxiety; Specific action; Stranger, fear of; Substitutive formation; Trauma of Birth, The .

Bibliography

Freud, Sigmund. (1895b [1894]). On the grounds for detaching a particular syndrome from neurasthenia under the description "anxiety neurosis." SE, 3: 87-115.

. (1926d [1925]). Inhibitions, symptoms and anxiety. SE, 20: 87-172.

. (1950a [1887-1902]). Extract from the Fliess papers. SE, 1: 173-280.

Klein, Melanie. (1946). Notes on some schizoid mechanisms. International Journal of Psycho-Analysis, 27, 99-110.

. (1948). On the theory of anxiety and guilt. International Journal of Psycho-Analysis, 29, 113-123.

Mahler, Margaret S., Pine, Fred, and Bergman, Anni. (1975). The psychological birth of the human infant. New York: Basic Books.

Palacio Espasa, Francisco. (1993). La pratique psychothérapique avec l'enfant. Paris: Bayard.

Further Reading

Hurvich, Marvin. (1997). "The ego in anxiety" & "Addendum to Freud's theory of anxiety". Psychoanalytic Review, 84, 483-504.

. (2000). Fear of being overwhelmed and psychoanalytic theories of anxiety. Psychoanalytic Review, 87, 615-650.

Roose, Stephen P. , and Glick, Robert. A. (Eds). (1995). Anxiety as symptom and signal. Hillsdale, NJ: Analytic Press.

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Anxiety

ANXIETY

Anxiety is a normal part of life, and it occurs over the entire life span. In particular, the experience of anxiety continues into later life. Just as younger people worry about things important to their stage of life, such as school, job, finances, and family, so too do older adults worry about health, family, finances, and their mortality. Elderly persons are as likely to react with fear or panic when danger is imminent as are their younger counterparts. Anxiety is a normal response to certain situations, and it can be useful in helping people to cope with problems and to manage threatening situations. Anxiety alerts us to threats and provides the physiological readiness needed for action. It may be very intense in certain situations yet still be considered normal. However, if it occurs when there is no threat, or if its intensity is far higher than the situation warrants, it is likely to be a symptom of an anxiety disorder. Excess anxiety that occurs repeatedly and leads to distress and disablement is usually caused by an anxiety disorder.

Elders are susceptible to many of the same treatable anxiety disorders that are seen in younger people. Sometimes this is because the disorder has been a lifelong condition. In other cases, its onset is in late life, and then risk factors are somewhat different than in younger people (see Figure 1). However, anxiety disorders seem to be more difficult to diagnose in the elderly population, and the treatments that have proven efficacy in younger populations are largely untested in elderly persons. The following three case examples exemplify the presentation of common anxiety disorders in older adults, and also illustrate the difficulties of diagnosing and treating these disorders.

Case one: generalized anxiety disorder

Ethel, age seventy-one, has always been a nervous woman. When interviewed by a psychiatrist, she describes feeling worried about future events that might happen. She explains she has had these worries "for as long as I can remember." At times, she has bouts with fatigue, headaches, and muscle aches. She says that what bothers her most is her chronic insomnia, and she has taken many different medications for sleep throughout her life. "I take my sleeping pills and I do just fine," she says. However, her family doesn't agree. Her daughter is distressed by Ethel's constant need for reassurance: "When mom's really worried about something, she'll phone me ten to twenty times in a day. Sometimes she seems paralyzed by her worries." When asked about this, Ethel reveals that she does have difficulty controlling her worries and that she takes an extra sleeping pill in the daytime for "nerves."

Ethel has classic signs of generalized anxiety disorder, a condition marked by constant distressing worries that the person finds difficult to control. Up to 2 percent of elderly people are afflicted by this condition at any time, which tends to be chronic (either constant throughout life, as in Ethel's case, or waxing and waning). Few people with this condition ever seek treatment for it. It is typical for older adults with generalized anxiety disorder to have many physical symptoms, such as Ethel's fatigue and headaches, so they often seek care from primary-care and specialty doctors for these physical symptoms, receiving unnecessary medical workups and medications without ever realizing the psychological basis for their problems.

When underlying anxiety is recognized by a doctor, it is often treated with a medication in the class called benzodiazepines. Valium (diazepam) is a well-known example of this type of medication. Unfortunately, this is not necessarily the best treatment, as benzodiazepines have side effects such as memory impairment, slowed reaction time (for example, when driving), and impaired balance, compounding problems an elderly person might have already. If so, these side effects are potentially of serious concern. Other treatments known to be efficacious for generalized anxiety disorder in younger adults, such as certain types of antidepressant medications and psychotherapies such as cognitive-behavior therapy may be better choices. However, these treatments have not yet been proven efficacious in the elderly population, though there are many reports of them alleviating this condition. In Ethel's case, her primary-care physician eventually convinced her of the underlying anxiety basis behind her symptoms and the need for a different type of medication. She was willing to try this because she trusted him, and within weeks both she and her daughter were feeling much better. She understood that this treatment would probably be needed long-term.

Case two: agoraphobia

Jim, age sixty-seven, never had any "nerve problems" in his life, according to his family. However, after suffering from a stroke, in which he lost movement on the left side of his body and fell, hurting his face and arm, he developed debilitating fears. After hospitalization, Jim received physical rehabilitation to help him regain his functioning. Nevertheless, he remains a "prisoner in his own home," as his son describes it: "Dad was fiercely independent before the stroke and did everything himself; now, he seems afraid to do anything alone." Jim says that because of his stroke-related weakness he can longer do many of the things outside the house that he used to do; he feels his walking is too unsteady. Jim's physical therapist is surprised at the degree of restriction. The therapist says that Jim does have enough strength; he simply becomes very fearful walking when someone is not nearby. When pressed, Jim agrees he has a great fear of falling: "Of course I'm scared; I could fall at any time and break my hip." Oddly, he is not reassured either by his physical therapist telling him that he is very unlikely to fall, nor by descriptions of other stroke sufferers who regained their independence. Jim cannot shake the anxiety that overcomes him when he thinks of going for a walk. As a result, Jim is considering moving from his home to a personal care home.

Jim's case is one of agoraphobia, literally "fear of the marketplace." This condition is characterized by fear of being trapped and unable to escape, or being alone and unable to get help in the event of having a physical problem. Agoraphobia is a common disorder in older individuals; it is estimated that it affects up to 8 percent of elderly persons. In younger individuals, agoraphobia usually develops after someone has experienced one or more panic attacks. In the elderly, however, agoraphobia often occurs for other reasons. Older adults can develop agoraphobia after medical events such as stroke, or traumatic events such as falls. The disorder can be difficult to detect, partly because the very nature of the disorder is to avoid going places, and this inhibits the person from seeking treatment. Jim's case exemplifies another diagnostic difficulty in the elderly: they often tend to normalize anxious behavior by either denying it exists or attributing it to realistic medical-related concerns.

Unfortunately, Jim's case illustrates a very common problemthat of anxiety disorders compounding or amplifying a disability caused by medical events. In Jim's case, a stroke that might only lead to minor changes in function is instead a severely disabling event when combined with agoraphobia. Another issue in this case is the need to rule out a depressive disorder. Depression is very common in elderly persons who have suffered medical events such as stroke, and it is frequently seen in those who suffer from an anxiety disorder. In Jim's case, his amplified disability might be not only from agoraphobia, but from depression as well. The optimal treatment of agoraphobia in younger adults is exposure therapy, by which the individual is repeatedly exposed to the feared situation while receiving professional advice from a therapist. As with other treatments for anxiety disorders, the efficacy of exposure therapy in older adults is unproven but promising. Some medications also help relieve agoraphobic symptoms, but these are also unproven in elderly persons.

Case three: obsessive-compulsive disorder

Susan, who is seventy, agrees that she is a very "clean" person. She spends much of each day cleaning and ordering her house. She describes having this behavior ever since childhood, when she avoided getting muddy and dirty. She says that her husband doesn't mind: "He says I'm a good housekeeper." Susan seems happy, too; proud of her clean house. However, more probing with questions reveals the extent of her problem: she explains that, all her life, she has felt very anxious about dirt, germs, and disorder. Earlier in her life she spent essentially all of each day cleaning, sometimes confining herself to one small square of a room, "so I could really get it clean." This behavior led to the loss of her only job (ironically, as a cleaning woman) and, for a time, estrangement from her husband and children. Her anxiety disorder was complicated by depression in her thirties and forties.

For the last several years, Susan has been taking a medication similar to Prozac (fluoxetine). She is doing much better: "Now I only spend three hours per day cleaning, and I can eat in a restaurant without bringing my disinfectant." But she still acknowledges significant distress at times, and while her relationship with her family is improved, there is still significant strain when her children bring their children over. "I just have to clench my teeth and bear it when they spill something."

Obsessive-compulsive disorder (OCD) is a combination of obsessionsrepetitive, intrusive, unwanted thoughts, images, or impulsesand compulsionsrepetitive acts done to ward off obsessions and/or to reduce anxiety. OCD occurs in about 1 percent of the elderly population and, since it is chronic, it will probably increase as individuals with this disorder enter the ranks of the aged. Susan's case exemplifies the chronic nature of OCD: she has suffered with it for sixty-plus years! Her case also illustrates an unfortunate complication of anxiety disorders: depression. The disability, in terms of job difficulties and strained relationships, is also typical of chronic anxiety disorders at any age. Susan's response to medications known as serotonin reuptake inhibitors is typical: helpful but incomplete. In younger adults, a type of psychotherapy known as behavior therapy can be effective; however its efficacy is unknown in elderly persons.

Other disorders

A panic attack is defined as a sudden intense feeling of fear associated with physical symptoms such as chest pain, shortness of breath, dizziness, shaking, feeling hot or cold, sweating, and nauseain short, the symptoms caused by adrenaline release in a fight-or-flight response. A typical panic attack lasts about ten minutes. Panic disorder is diagnosed in people who have recurrent unexpected panic attacks along with persistent fear of these attacks or fear of what they mean or what they might cause. While this disorder is believed to be relatively rare in the elderly population, it may be that the disorder is difficult to diagnose because elderly individuals and their doctors attribute such physical symptoms to cardiac, respiratory, or other medical conditions. This misattribution has been illustrated earlier in this entry with other types of anxiety disorders as well.

Social phobia, also called social anxiety disorder, is a common disorder that typically begins early in life and usually lasts in some form throughout the life span; not surprisingly, it is seen in elderly persons, with about 1 percent suffering from the disorder. Its main feature is a fear of being criticized or humiliated while being observed or scrutinized by others. Its most common form is stage fright, or public-speaking phobia, but in the more severe cases, fear of eating, talking, or even being seen in public can paralyze individuals. Typically, elderly persons will have lived with this disorder for their entire lifetime and have adapted; that is, they have avoided feared situations (such as speaking in public) for so long that they view their lives as unaffected.

Specific phobias are the most common anxiety disorders: they are an intense, irrational fear of some situation. Common examples are acrophobia: fear of high places; and claustrophobia: fear of enclosed places. While considered less severe than other disorders, they can sometimes be quite disabling (e.g., the acrophobic who quits his job in a high-rise building). Similar to social phobia, elderly persons with specific phobias will probably have had these conditions for their entire life and have changed their lifestyle to avoid the feared situation or object.

Post-traumatic stress disorder (PTSD) is a type of response to an event that threatens or causes serious physical harm or even death, while also causing feelings of horror and/or helplessness. For example, being mugged or raped, or being shot at in battle can cause PTSD. It is diagnosed if the individual reexperiences the trauma in the form of nightmares, visions, or flashbacks, and if he or she exhibits chronic avoidance behavior and hyperarousability. The prevalence of this disorder is unknown in older adults. While it is common in such groups as combat veterans, it can also occur after serious medical events such as stroke and heart attack. In younger adults, PTSD tends to be chronic, lasting decades, and it is typically only partly responsive to medication (serotonin reuptake inhibitors). The course and response to treatment of this disorder in elderly persons is unknown, but as the combat veterans from the Korean and Vietnam wars grow older, much more will need to be known about this disorder as it presents in older adults.

Many older adults have problems with anxiety at some point in their life but do not have symptoms that meet the criteria for one (or more) of the above-described disorders. This is partly because the disorders described above were validated in younger age groups; thus, they may not describe the underlying disorder of many elderly persons suffering from symptomatic anxiety. As research in the field of geriatric psychiatry increases, anxiety disorders unique to older adults may be discovered. In any event, an older adult who suffers from anxiety should not be dismissed simply because their symptoms do not share features with the disorders described above.

The case examples presented here show some typical features of anxiety disorders as they present in older adults: they are common, though less so than younger adults, and they are not simply a "normal" reaction to aging or medical events. Further, they tend to be chronic and lead to much distress and disability, especially in combination with disabling chronic medical conditions such as stroke.

The problems with recognition and treatment of anxiety disorders in later life are twofold. First, there is the difficulty recognizing the disorder in an individual who may have lived with anxiety their entire life and view it as normal, or who may misattribute anxiety symptoms to medical problems common in this age group. Second, treatment options are for the most part unproven in older populations, due to the lack of controlled clinical trials for elderly persons with anxiety disorders. On the other hand, it is known that elderly people with depression respond to medication and psychotherapy just like their younger counterparts, and it is likely that this will be true for anxiety disorders as well. In the future, understanding of the presentation and treatment of anxiety disorders in the elderly will improve if there is better education of the public about these disorders and more treatment research to assure that potential treatments can find their place with elderly populations, just as in younger adults.

Eric Lenze M. Katherine Shear

See also Death Anxiety; Depression; Geriatric Psychiatry.

BIBLIOGRAPHY

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: APA, 1994.

Beekman, A. T. F.; de Beurs, E.; van Balkom, A. J. L. M.; Deeg, D. J. H.; van Dyck, R.; and van Tilburg, W. "Anxiety and Depression in Later Life. Co-occurrence and Communality of Risk Factors." American Journal of Psychiatry 157 (2000): 8995.

Flint, A. J. "Epidemiology and Comorbidity of Anxiety Disorders in the Elderly." American Journal of Psychiatry 151 (1994): 640649.

Flint, A. J. "Management of Anxiety in Late Life." Journal of Geriatric Psychiatry 11 (1998): 194200.

Krasucki, C.; Howard, R.; and Mann, A. "Anxiety and Its Treatment in the Elderly." International Psychogeriatrics 11 (1999): 2545.

APHASIA

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Anxiety

Anxiety

Definition

Anxiety is a condition of persistent and uncontrollable nervousness, stress, and worry that is triggered by anticipation of future events, memories of past events, or ruminations over day-to-day events, both trivial and major, with disproportionate fears of catastrophic consequences.

Description

Stimulated by real or imagined dangers, anxiety affects people of all ages and social backgrounds. When it occurs in unrealistic situations or with unusual intensity, it can disrupt everyday life. Some researchers believe anxiety is synonymous with fear , occurring in varying degrees and in situations in which people feel threatened by some danger. Others describe anxiety as an unpleasant emotion caused by unidentifiable dangers or dangers that, in reality, pose no threat. Unlike fear, which is caused by realistic, known dangers, anxiety can be more difficult to identify and alleviate.

A small amount of anxiety is normal in the developing child, especially among adolescents and teens. Anxiety is often a realistic response to new roles and responsibilities, as well as to sexual and identity development. When symptoms become extreme, disabling, and/or when children or adolescents experience several symptoms over a period of a month or more, these symptoms may be a sign of an anxiety disorder, and professional intervention may be necessary. Two common forms of childhood anxiety are general anxiety disorder (GAD) and separation anxiety disorder (SAD), although many physicians and psychologists also include panic disorder and obsessive-compulsive disorder , which tend to occur more frequently in adults. Anxiety that is the result of experiencing a violent event, disaster, or physical abuse is identified as post-traumatic stress disorder (PTSD). Most adult anxiety disorders begin in adolescence or young adulthood and are more common among women than men.

Demographics

According to the U.S. surgeon general, 13 percent, or over 6 million children, suffer from anxiety, making it the most common emotional problem in children. Among adolescents, more girls than boys are affected. About half of the children and adolescents with anxiety disorders also have a second anxiety disorder or other mental or behavioral disorder, such as depression.

Causes and symptoms

A child's genetics, biochemistry, environment, history, and psychological profile all seem to contribute to the development of anxiety disorders. Most children with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the rest of the population.

Emotional and behavioral symptoms of anxiety disorders include tension; self-consciousness; new or recurring fears (such as fear of the dark, fear of being alone, or fear of strangers); self-doubt and questioning; crying and whining; worries; constant need for reassurance (clinging to parent and unwilling to let the parent out of sight); distractibility; decreased appetite or other changes in eating habits; inability to control emotions; feeling as if one is about to have a heart attack, die, or go insane; nightmares ; irritability, stubbornness, and anger; regression to behaviors that are typical of an earlier developmental stage; and unwillingness to participate in family and school activities. Physical symptoms include rapid heartbeat; sweating; trembling; muscle aches (from tension); dry mouth; headache ; stomach distress; diarrhea; constipation ; frequent urination; new or recurrent bedwetting; stuttering ; hot flashes or chills; throat constriction (lump in the throat); sleep disturbances; and fatigue. Many of these anxiety symptoms are very similar to those of depression, and as many as 50 percent of children with anxiety also suffer from depression. Generally, physiological hyperarousal (excitedness, shortness of breath, the fight or flight response) characterizes anxiety disorders, whereas underarousal (lack of pleasure and feelings of guilt) characterizes depression. Other signs of anxiety problems are poor school performance, loss of interest in previously enjoyed activities, obsession about appearance or weight, social phobias (e.g., fear of walking into a room full of people), and the persistence of imaginary fears after ages six to eight. Children with anxiety disorders are often perfectionists and are concerned about "getting everything right," but rarely feel that their work is satisfactory.

Shyness does not necessarily indicate a disorder, unless it interferes with normal activities and occurs with other symptoms. A small proportion of children do experience social anxiety, incapacitating shyness that persists for months or more, which should be treated. Similarly, performance anxiety experienced before athletic, academic, or theatrical events does not indicate a disorder, unless it significantly interferes with the activity.

Separation anxiety disorder (SAD) is the most common anxiety disorder among children, affecting 2 to 3 percent of school-aged children. SAD involves extreme and disproportionate distress over day-to-day separation from parents or home and unrealistic fears of harm to self or loved ones. Approximately 75 to 85 percent of children who refuse to go to school have separation anxiety. Normal separation fears are outgrown by children by the ages of five or six, but SAD usually starts between the ages of seven and 11.

When to call the doctor

A qualified mental health professional should be consulted if a child's anxiety begins to affect his or her ability to perform the three main responsibilities of childhood: to learn, to make friends, and to have fun. Often fears and anxieties come and go with time and age. However, in some children, anxiety becomes severe, excessive, unreasonable, and long-lasting (usually considered as long-lasting if the child experiences the elevated level of anxiety for a month or more), interferes with the child's ability to function normally, and causes the child to be distraught and easily upset, thus necessitating professional intervention.

Diagnosis

Diagnosing children with an anxiety disorder can be very difficult, since anxiety often results in disruptive behaviors that overlap with other disorders such as attention-deficit hyperactivity. Children showing signs of an anxiety disorder should first get a physical exam to rule out any possible illness or physical problem. Diagnosis of normal versus abnormal anxiety depends largely upon the degree of distress and its effect on a child's functioning. The degree of abnormality must be gauged within the context of the child's age and developmental level. The specific anxiety disorder is diagnosed by the pattern and intensity of symptoms using various psychological diagnostic tools.

Treatment

Depending on the severity of the problem, treatments for anxiety include school counseling, family therapy , and cognitive-behavioral or dynamic psychotherapy, sometimes combined with antianxiety drugs. Therapies generally aim for support by providing a positive, entirely accepting, pressure-free environment in which to explore problems; by providing insight through discovering and working with the child or adolescent's underlying thoughts and beliefs; and by exposure through gradually reintroducing the anxiety-producing thoughts, people, situations, or events in a manner so as to confront them calmly. Relaxation techniques, including meditation, may be employed in order to control the symptoms of physiological arousal and provide a tool the child can use to control his or her response.

Creative visualization, sometimes called rehearsal imagery by actors and athletes, may also be used. In this technique, the child writes down (or draws pictures of) each detail of the anxiety-producing event or situation and imagines his or her movements in performing the activity. The child also learns to perform these techniques in new, unanticipated situations.

In severe cases of diagnosed anxiety disorders, anti-anxiety and/or antidepressant drugs may be prescribed in order to enable therapy and normal daily activities to continue. Previously, narcotics and other sedatives, drugs that are highly addictive and interfere with cognitive capacity, were prescribed. With pharmacological advances and the development of synthetic drugs, which act in specific ways on brain chemicals, a more refined set of antianxiety drugs became available. Studies have found that generalized anxiety responds well to these drugs (benxodiazepines are the most common), which serve to quell the physiological symptoms of anxiety. Other forms of anxiety such as panic attacks, in which the symptoms occur in isolated episodes and are predominantly physical (and the object of fear is vague, fantastic, or unknown), respond best to the antidepressant drugs. Childhood separation anxiety is thought to be included in this category. Psychoactive drugs should only be considered as a last treatment alternative, and extra caution should be used when they are prescribed for children.

Prognosis

Studies consistently report that anxiety disorders can be debilitating and impinge seriously on a person's quality of life. Despite their common occurrence, little is underbstood about the natural course of anxiety disorder. Adults experiencing anxiety disorders often report that they have felt anxious all of their lives, with one half of adults with general anxiety disorder reporting that the onset of the condition occurred during childhood or adolescence. Anxiety disorders can be chronic, and the severity of symptoms can fluctuate significantly, with symptoms being more severe when stressors are present. Without treatment, extended periods of remission are not likely.

Prevention

Parents can help their child respond to stress by taking the following steps:

  • providing a safe, secure, familiar, and consistent home life
  • being selective in the types of television programs that children watch (including news shows), which can produce fears and anxieties
  • spending calm and relaxed time with their child
  • encouraging questions and expressions of fears, worries, or concerns
  • listening to the child with encouragement and affection and without being critical
  • rewarding (and not punishing) the child for effort rather than success
  • providing the child with opportunities to make choices; with more control over situations, the child has a better response to stress
  • involving the child in activities in which he or she can succeed and limiting events and situations that are stressful for the child
  • developing an awareness of the situations and activities that are stressful for the child and recognizing signs of stress in the child
  • keeping the child informed of necessary and anticipated changes (e.g., moving, change of school) that may cause the child to be stressed
  • seeking professional help or advice when the symptoms of stress do not decrease or disappear

The child should also be encouraged to use various techniques to reduce stress, including the following strategies:

  • talking about problems to parents or others whom the child trusts
  • relaxing by listening to music, taking a warm bath, meditating, practicing breathing exercises, or participating in a favorite hobby or activity
  • exercising
  • respecting themselves and others
  • avoiding the use of drugs and alcohol
  • feeling free to ask for help if he or she is having difficulties with stress management

KEY TERMS

Psychological Pertaining to the mind, its mental processes, and its emotional makeup.

Psychotherapy Psychological counseling that seeks to determine the underlying causes of a patient's depression. The form of this counseling may be cognitive/behavioral, interpersonal, or psychodynamic.

Shyness The feeling of insecurity when among people, talking with people, or asking somebody a favor.

Stress A physical and psychological response that results from being exposed to a demand or pressure.

Parental concerns

Parenting an anxious child is difficult and can create stress within the entire family. Parents need to help the child learn and apply techniques to manage his or her anxiety. The use of support groups and professional assistance is recommended.

Parents of children with anxiety disorders may exhibit anxiety symptoms themselves and should also seek professional assistance.

See also Fear; Separation anxiety.

Resources

BOOKS

Chansky, Tamar E. Freeing Your Child from Anxiety: Powerful, Practical Solutions to Overcome Your Child's Fears, Worries, and Phobias. New York: Broadway Books, 2004.

Dacey, John S., and Lisa B. Fiore. Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children. New York: John Wiley & Sons, 2001.

Fox, Paul. The Worried Child: Recognizing Anxiety in Children and Helping Them Heal. Alameda, CA: Hunter House Publishers, 2004.

Rapee, Ron, Sue Spence, and Ann Wignall. Helping Your Anxious Child. Oakland, CA: New Harbinger Publications, 2000.

Spencer, Elizabeth, Robert L. Dupont, and Caroline M. Dupont. The Anxiety Cure for Kids: A Guide for Parents. New York: John Wiley & Sons Inc., 2003.

Wagner, Aureen Pinto Worried No More: Help and Hope for Anxious Children. Rochester, NY: Lighthouse Press Inc., 2002.

ORGANIZATIONS

Anxiety Disorders Association of America. 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site: <www.adaa.org>.

National Institute of Mental Health (NIMH), Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Web site: <www.nimh.nih.gov/>.

WEB SITES

The Child Anxiety Network. <www.childanxiety.net/> (accessed October 11, 2004).

Judith Sims

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Anxiety Disorders

Anxiety Disorders

Definition

The anxiety disorders are a group of mental disturbances characterized by anxiety as a central or core symptom. Although anxiety is a commonplace experience, not everyone who experiences it has an anxiety disorder. Anxiety is associated with a wide range of physical illnesses, medication side effects, and other psychiatric disorders.

The revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that took place after 1980 brought major changes in the classification of the anxiety disorders. Prior to 1980, psychiatrists classified patients on the basis of a theory that defined anxiety as the outcome of unconscious conflicts in the patient's mind. DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) introduced and refined a new classification that considered recent discoveries about the biochemical and post-traumatic origins of some types of anxiety. The present definitions are based on the external and reported symptom patterns of the disorders rather than on theories about their origins.

Description

Anxiety disorders are the most common form of mental disturbance in the United States population. It is estimated that 28 million people suffer from an anxiety disorder every year. These disorders are a serious problem for the entire society because of their interference with patients' work, schooling, and family life. They also contribute to the high rates of alcohol and substance abuse in the United States. Anxiety disorders are an additional problem for health professionals because the physical symptoms of anxiety frequently bring people to primary care doctors or emergency rooms.

DSM-IV defines 12 types of anxiety disorders in the adult population. They can be grouped under seven headings:

  • Panic disorders with or without agoraphobia. The chief characteristic of panic disorder is the occurrence of panic attacks coupled with fear of their recurrence. In clinical settings, agoraphobia is usually not a disorder byitself, but is typically associated with some form of panic disorder. Patients with agoraphobia are afraid of places or situations in which they might have a panic attack and be unable to leave or to find help. About 25% of patients with panic disorder develop obsessive-compulsive disorder (OCD).
  • Phobias. These include specific phobias and social phobia. A phobia is an intense irrational fear of a specific object or situation that compels the patient to avoid it. Some phobias concern activities or objects that involve some risk (for example, flying or driving) but many are focused on harmless animals or other objects. Social phobia involves a fear of being humiliated, judged, or scrutinized. It manifests itself as a fear of performing certain functions in the presence of others, such as public speaking or using public lavatories.
  • Obsessive-compulsive disorder (OCD). This disorder is marked by unwanted, intrusive, persistent thoughts or repetitive behaviors that reflect the patient's anxiety or attempts to control it. It affects between 2-3% of the population and is much more common than was previously thought.
  • Stress disorders. These include post-traumatic stress disorder (PTSD) and acute stress disorder. Stress disorders are symptomatic reactions to traumatic events in the patient's life.
  • Generalized anxiety disorder (GAD). GAD is the most commonly diagnosed anxiety disorder and occurs most frequently in young adults.
  • Anxiety disorders due to known physical causes. These include general medical conditions or substance abuse.
  • Anxiety disorder not otherwise specified. This last category is not a separate type of disorder, but is included to cover symptoms that do not meet the specific DSM-IV criteria for other anxiety disorders.

All DSM-IV anxiety disorder diagnoses include a criterion of severity. The anxiety must be severe enough to interfere significantly with the patient's occupational or educational functioning, social activities or close relationships, and other customary activities.

The anxiety disorders vary widely in their frequency of occurrence in the general population, age of onset, family patterns, and gender distribution. The stress disorders and anxiety disorders caused by medical conditions or substance abuse are less age- and gender-specific. Whereas OCD affects males and females equally, GAD, panic disorder, and specific phobias all affect women more frequently than men. GAD and panic disorders are more likely to develop in young adults, while phobias and OCD can begin in childhood.

Anxiety disorders in children and adolescents

DSM-IV defines one anxiety disorder as specific to children, namely, separation anxiety disorder. This disorder is defined as anxiety regarding separation from home or family that is excessive or inappropriate for the child's age. In some children, separation anxiety takes the form of school avoidance.

Children and adolescents can also be diagnosed with panic disorder, phobias, generalized anxiety disorder, and the post-traumatic stress syndromes.

Causes and symptoms

The causes of anxiety include a variety of individual and general social factors, and may produce physical, cognitive, emotional, or behavioral symptoms. The patient's ethnic or cultural background may also influence his or her vulnerability to certain forms of anxiety. Genetic factors that lead to biochemical abnormalities may also play a role.

KEY TERMS

Agoraphobia Abnormal anxiety regarding public places or situations from which the patient may wish to flee or in which he or she would be helpless in the event of a panic attack.

Compulsion A repetitive or ritualistic behavior that a person performs to reduce anxiety. Compulsions often develop as a way of controlling or "undoing" obsessive thoughts.

Obsession A repetitive or persistent thought, idea, or impulse that is perceived as inappropriate and distressing.

Panic attack A time-limited period of intense fear accompanied by physical and cognitive symptoms. Panic attacks may be unexpected or triggered by specific cues.

Anxiety in children may be caused by suffering from abuse, as well as by the factors that cause anxiety in adults.

Diagnosis

The diagnosis of anxiety disorders is complicated by the variety of causes of anxiety and the range of disorders that may include anxiety as a symptom. Many patients who suffer from anxiety disorders have features or symptoms of more than one disorder. Patients whose anxiety is accounted for by another psychic disorder, such as schizophrenia or major depression, are not diagnosed with an anxiety disorder. A doctor examining an anxious patient will usually begin by ruling out diseases that are known to cause anxiety and then proceed to take the patient's medication history, in order to exclude side effects of prescription drugs. Most doctors will ask about caffeine consumption to see if the patient's dietary habits are a factor. The patient's work and family situation will also be discussed. Often, primary care physicians will exhaust resources looking for medical causes for general patient complaints which may indicate a physical illness. In 2004, the Anxiety Disorders Association of American published guidelines to better aid physicians in diagnosing and managing generalized anxiety disorder. Laboratory tests for blood sugar and thyroid function are also common.

Diagnostic testing for anxiety

There are no laboratory tests that can diagnose anxiety, although the doctor may order some specific tests to rule out disease conditions. Although there is no psychiatric test that can provide definite diagnoses of anxiety disorders, there are several short-answer interviews or symptom inventories that doctors can use to evaluate the intensity of a patient's anxiety and some of its associated features. These measures include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).

Treatment

For relatively mild anxiety disorders, psychotherapy alone may suffice. In general, doctors prefer to use a combination of medications and psychotherapy with more severely anxious patients. Most patients respond better to a combination of treatment methods than to either medications or psychotherapy in isolation. Because of the variety of medications and treatment approaches that are used to treat anxiety disorders, the doctor cannot predict in advance which combination will be most helpful to a specific patient. In many cases the doctor will need to try a new medication or treatment over a six- to eight-week period in order to assess its effectiveness. Treatment trials do not necessarily mean that the patient cannot be helped or that the doctor is incompetent.

Although anxiety disorders are not always easy to diagnose, there are several reasons why it is important for patients with severe anxiety symptoms to get help. Anxiety doesn't always go away by itself; it often progresses to panic attacks, phobias, and episodes of depression. Untreated anxiety disorders may eventually lead to a diagnosis of major depression, or interfere with the patient's education or ability to keep a job. In addition, many anxious patients develop addictions to drugs or alcohol when they try to "medicate" their symptoms. Moreover, since children learn ways of coping with anxiety from their parents, adults who get help for anxiety disorders are in a better position to help their families cope with factors that lead to anxiety than those who remain untreated.

Alternative treatment

Alternative treatments for anxiety cover a variety of approaches. Meditation and mindfulness training are thought beneficial to patients with phobias and panic disorder. Hydrotherapy is useful to some anxious patients because it promotes general relaxation of the nervous system. Yoga, aikido, t'ai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

Homeopathy and traditional Chinese medicine approach anxiety as a symptom of a systemic disorder. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Chinese medicine regards anxiety as a blockage of qi, or vital force, inside the patient's body that is most likely to affect the lung and large intestine meridian flow. The practitioner of Chinese medicine chooses acupuncture point locations and/or herbal therapy to move the qi and rebalance the entire system in relation to the lung and large intestine.

Prognosis

The prognosis for recovery depends on the specific disorder, the severity of the patient's symptoms, the specific causes of the anxiety, and the patient's degree of control over these causes.

Prevention

Anxiety is an unavoidable feature of human existence. However, humans have some power over their reactions to anxiety-provoking events and situations. Cognitive therapy and meditation or mindfulness training appear to be beneficial in helping people lower their long-term anxiety levels.

Resources

PERIODICALS

"Guidelines to Assist Primary Care Physicians in Diagnosing GAD." Psychiatric Times (July 1, 2004): 16.

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Anxiety

Anxiety

BIBLIOGRAPHY

Anxiety is a universally experienced emotion felt as an unpleasant, tense anticipation of an impending but vague threat. Some 18 percent of the adult U.S. population experiences anxiety symptoms to the extent that they can be diagnosed as suffering from an anxiety disorder. Anxious people often feel as if something bad were about to happen to them, although they might be unable to identify an immediate threat. The emotion of anxiety is in many ways similar to fear, although fear is typically defined as an emotional reaction to a clearly identifiable threat, such as a charging elephant or the possibility of falling when leaning over the edge of a tall building.

Fear and anxiety have in common several reaction patterns. One typical anxiety response is a sense of choking or constriction, felt as a lump in the throat. Indeed, the Latin root of the term anxiety is angh, meaning constriction. Also related is the Germanic word angst. However, an anxiety reaction is more than a lump in the throat, as described by psychologist Stanley J. Rachman, one of the leading authorities on anxiety and anxiety disorders. Most experts agree that there are three partially integrated response systems that account for the various symptoms and therefore make up the full experience of anxiety. These are the cognitive, physiological, and behavioral response systems. Examples of each are described in Table 1.

Sigmund Freud (1856-1939), the founder of psychoanalysis in the late nineteenth century, is credited with explication of the role of anxiety in affecting peoples daily lives. Freud postulated three types of anxiety. He called a reaction to a real or potential threat reality anxiety, whereas anxiety generated within the psychic apparatus as a threat to the ego was called neurotic anxiety. According to Freud, the ego keeps its instinctual sources of threat out of conscious awareness so that the true source of neurotic anxiety remains obscure and is experienced as free-floating or unattached anxiety. Freud also described moral anxiety, arising from an impending or actual violation of internalized standards. Moral anxiety is experienced as shame or guilt.

Table 1
Response components that make up the experience of anxiety
Cognitive: Thoughts that something is wrong, a sense of dread, worry about many things, and difficulty concentrating.
Physiological: Increased activation of the sympathetic nervous system leading to increases in heart rate, blood pressure, perspiration, respiration rate, pupil dilation, and muscle tension.
Behavioral: Fidgeting, pacing, jittery movements, irritableness, stuttering, flight from or active avoidance of a harmless but feared situation.

Another, more recent characterization of anxiety types is psychologist Charles Spielbergers state-trait distinction. State anxiety refers to an individuals anxious feeling at a given time: Are you anxious right now? Trait anxiety refers to ones state of anxiety in general: Are you an anxious person? State anxiety is more akin to fear as a response to a specific situation, whereas trait anxiety is part of ones overall personality.

The most common source of anxiety or fear is the perception that one is in imminent psychological or physical danger, or might be at some future time, such as feeling anxious about an impending dental appointment. Another common source of anxiety is concern over what other people might think of you. This social anxiety is particularly prevalent among adolescents, who worry that they might be scrutinized by others and be found lacking in appearance, skills, or behavior.

Although most anxiety is precipitated by perceived environmental threats, there are clear individual differences in how people perceive and react to potential threats. There is good evidence that some people are genetically predisposed to be more anxiety-reactive than others. Furthermore, a number of physical and medical conditions can cause anxiety symptoms that resolve when the condition is successfully treated. A sample of these anxiety inducing medical conditions is shown in Table 2.

The experience of anxiety is virtually universal among humans and most vertebrate animals. Most anxiety is experienced within the normal range, where it escalates under perceived stressful situations (e.g., taking a test) and then diminishes as the threat wanes. However, for those whose anxiety is severe enough to be diagnosed as an anxiety disorder, the experience of anxiety is chronic, debilitating, and interferes with personal, social, and occupational functioning. The various disorders have in common an exaggerated sense of fear, anxiety, and dread; yet each has a distinctive pattern to its expression.

Table 2
Physical conditions that can cause anxiety symptoms
Disordered system Example conditions or substances
Endocrine disordershypoglycemia, hyperthyroidism
Cardiovascular disordersmitral valve prolapse, angina pectoris, arrhythmia
Respiratory disordershyperventilation, chronic obstructive pulmonary syndrome
Metabolic disordersvitamin B12 deficiency
Neurologic disorderspostconcussive syndrome, vestibular dysfunction
Toxinspaint, gasoline, insecticides
Drug intakealcohol, amphetamines, sedatives, antihistamines
Drug withdrawalsedatives, alcohol, cocaine

Specific phobias are morbid and irrational (relative to the potential for actual danger) fear reactions to specific objects and situations. The phobic person attempts to avoid or escape from these objects or situations at all cost. Common examples include phobias of small animals (e.g., rats, snakes, spiders), heights, and injections of medicine. Social phobia involves fear and anxiety reactions to situations in which a person believes that he or she might be observed by others and be negatively evaluated or might embarrass himself or herself. Public speaking, using public restrooms, and eating in public are among the more common social phobia situations.

Generalized anxiety disorder involves a chronic state of worry, apprehension, and anticipation of possible disaster, no matter how unlikely it is that the disaster will occur. Individuals with panic disorder might have a sudden attack of intense anxiety or panic that hits them unexpectedly, out of the blue. In certain cases, when these unexpected panic attacks occur outside the home, people become fearful that another attack might strike if they go out again. When they become so fearful of having another attack that they cannot leave their home or safe haven, they are diagnosed as having panic disorder with agoraphobia. Posttraumatic stress disorder can occur following a terrifying event. The person might experience persistent, frightening thoughts and images as flashbacks to the original trauma. Individuals with obsessive-compulsive disorder experience anxiety-related thoughts and feel compelled to enact compulsive rituals, such as washing their hands repeatedly, lest they experience even more intense anxiety.

One of the most serious consequences of untreated chronic anxiety disorders, which are often accompanied by depression, is the increased risk of substance abuse as a form of self-medication. Other consequences of the constant

Table 3
Drugs for treating anxiety disorders
Drug class Examples of trade names
Antianxiety:  
Benzodiazepines:Valium, Librium, Klonopin, Xanax, Ativan
Buspirone:BuSpar
Antidepressants:  
Selective serotonin reuptake inhibitors:Paxil, Zoloft, Prozac, Clozapine, Luvox
Tricyclic antidepressants:Elavil, Endep, Anafranil

worry and accompanying physical tension are gastrointestinal distress, insomnia, headache, high blood pressure, hyperventilation, nausea, and fatigue.

Anxiety disorders are among the most successfully treated of all mental disorders. Two basic approaches contribute to this effectiveness: psychotherapy (specifically, cognitive-behavioral therapy ) and pharmacotherapy. The effective therapeutic processes in cognitive-behavioral therapy include helping patients alter negative anticipatory thoughts that often trigger anxiety symptoms and helping them confront their feared situations directly, which allows the anxiety symptoms to dissipate. To facilitate these processes, training in cognitive coping skills and deep relaxation are typically included in a cognitive-behavioral therapy treatment protocol.

Two classes of drugs are known to be effective in treating some anxiety disorders. Antianxiety drugs, primarily benzodiazepines, can reduce anxiety and panic symptoms but they have the serious drawback of physical dependency if taken for extended periods. Many antidepressants, particularly selective serotonin reuptake inhibitors and tricyclics, also have antianxiety properties. Examples of these antianxiety drugs are listed in Table 3.

SEE ALSO Coping; Mental Health; Phobia; Psychotherapy; Social Anxiety; Stress

BIBLIOGRAPHY

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR). 4th ed., text rev. Washington, DC: Author.

Barlow, David H. 2002. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. 2nd ed. New York: Guilford.

Rachman, Stanley J. 2004. Anxiety. 2nd ed. East Sussex, U.K.: Psychology Press.

Ronald A. Kleinknecht

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anxiety

anxiety is an emotional state, represented by a feeling of dread, apprehension, or fear. In humans, this can be defined by description using language; in animals, it must be inferred from behavioural observations. Tests of anxiety in man are thus based on self report, and these may be divided into features that characterize the person's temperament (‘trait’ anxiety) or that describe a current emotional state (‘state’ anxiety). In animals, it is inferred by the animal's response to an anxiety-provoking situation such as a threatening environment. Distinctions between anxiety and other emotional states, such as fear or even ‘arousal’, are not always clear. Also, there are close associations between cognition and emotion: man has the capacity not only to know, but also to respond emotionally to what he knows.

However, anxiety is not only a behavioural phenomenon. Characteristic autonomic changes take place, typically including increased heart rate and/or blood pressure. There is also marked endocrine activation, particularly increased secretion of the adrenal hormones adrenaline (and noradrenaline) and cortisol (the ‘stress’ hormone). There has been much discussion of how far these ‘peripheral’ events can actually induce emotional states such as anxiety, or are part of the body's response to those states. Current opinion puts most emphasis on ‘central’ instigation (by neural mechanisms), though it may be true that accentuated autonomic activity can elicit emotional states, especially when there is a perceived rationale for such activity — ‘cognitive labelling’. Persistent changes in certain hormones (for example, cortisol) may alter the ability of an individual to respond anxiously to provoking stimuli.

Biologically, anxiety has a prime function in adapting to, or avoiding, threatening situations. In animals, one of many ways of inducing such a presumed response would be by pairing a neutral stimulus (say, a light) with a consequent aversive stimulus (such as a footshock). After several such pairings, presentation of the light alone will result in the behavioural and physiological features of anxiety. Similar features can be elicited by exposing animals to situations that they find naturally threatening, such as strange surroundings, or physical peril. This implies that a state of high anxiety is aversive — borne out in humans by the demand for drugs that reduce it, and in animals by showing that they will work to reduce their anxiety levels. Because animals and people find anxiety aversive, they will avoid those circumstances that give rise to it, and hence the threat itself. ‘Fear’ can be substituted for ‘anxiety’ in many of these contexts.

Anxiety can, therefore, be the result of stimuli which are naturally threatening (for example the response of a rat to the presence of a cat), those that have been associated with previous danger (the surroundings where the cat is found), or stimuli that are not in themselves threatening, but have become so because of a learned association between them and subsequent discomfort or threat.

Clinically, if significant or disabling levels of anxiety occur without there being sufficient apparent cause, either current or past, then the patient is said to suffer from an anxiety disorder. These disorders can be ‘global’, or generalized, in those people who have high levels of anxiety without evident provoking events; or they can be ‘specific’, where high anxiety is induced by circumstances which, for most people, would not be considered anxiogenic (such as open spaces, spiders, meeting people) — these are sometimes termed ‘phobias’. In some cases, anxiety occurs in sudden waves (‘panic attacks’). Anxiety may also occur as part of another medical condition, or as one result of a drug of abuse or a medication. Post-traumatic stress disorder is a particular form of anxious attack provoked by involuntary recall of a previously life-threatening episode (usually triggered by some salient stimulus; for example the sound of a helicopter in those traumatized by war). Psychoanalytical theory has been much concerned with the causes and meaning of individual differences in anxiety.

Attempts have been made to define particular parts of the brain that may be responsible both for physiological or pathological anxiety. There is general agreement that damage to the amygdala can reduce anxiety, both that which is a response to ‘natural’ stimuli and that generated by learned associations. The amygdala (or amygdaloid complex, or nucleus) is a collection of grey matter that is part of the limbic system, situated in each temporal lobe of the brain, between the cerebral cortex and the hypothalamus. It consists of a number of sub-components (nuclei), and some evidence is emerging that different nuclei in the amygdala may play defined roles in certain forms of anxiety. Electrical or chemical stimulation of the amygdala may induce anxiety-like states. There are those who think that the principal or only role of the amygdala is to generate fear or anxiety-like states, but it is more likely that this is one special case of a more general role for this part of the brain. Humans with congenital damage to the amygdala may also have difficulty, for example, in recognizing emotionality, such as fear, in others, or the emotional content of stories.

Scans of the brain by magnetic resonance imaging (MRI) show that the amygdala is activated by stimuli that induce or represent emotional states, including fear or anxiety. However, MRI and other imaging techniques have also shown many other parts of the brain to be activated in anxiety states, depending on the condition being studied, or the way in which anxiety is generated; these include parts of the cortex of the frontal lobes, known to be involved in emotional responses, and closely associated cortical areas. There are many connections between the amygdala and these areas of cortex. There is some evidence in the human brain for asymmetry in the role of the frontal cortex: the right side may be particularly important in aversive emotional states such as anxiety.

A number of chemical systems in the brain have been implicated in anxiety. The discovery that the benzodiazepine drugs (e.g. librium, valium) had major and quite specific anxiety-reducing (anxiolytic) effects on both humans and experimental animals prompted the search for chemicals in the brain that might regulate anxiety levels. Benzodiazepines act by antagonizing the neurotransmitter GABA (γ-amino-butyric acid), a compound widely used by nerve cells in the brain to inhibit the activity of other nerve cells. Why this should result in a specific effect on anxiety remains an enigma. At one time, many millions of prescriptions for benzodiazepines were written each year, but it has now become apparent that persistent use may have undesirable side effects, including rebound anxiety once they are discontinued. They nevertheless remain a staple treatment for anxiety disorders. Drugs acting on other systems also have clinically useful anxiolytic effects; these include drugs that modify the action in the brain of serotonin or of noradrenaline. Both serotonin and noradrenaline are activated in the brain by anxiety-inducing circumstances.

More recently, certain peptides in the brain have been shown to be involved in anxiety. One is corticotrophin-releasing factor (CRF). This peptide, when infused into the brain of an experimental animal, results in anxiety-like behaviour, as well as the other physiological signs of anxiety. CRF acts on specific receptors on neuronal cell membranes in the brain. These have been shown to be responsible for its anxiogenic actions, because drugs that block CRF1 receptors, or animals that are bred without these receptors (CRF1R-deficient transgenic mice), show reduced anxiety. CRF antagonists may, therefore, be the precursors of a new generation of anti-anxiety drugs. However, CRF has other behavioural effects, including actions on food intake and sexual behaviour, and it remains to be established whether other categories of receptors are responsible for these various roles. It is also not clear whether anxiety disorders can be related to inappropriate amounts of these normal neuropeptides, or to the presence of abnormal molecules.

J. Herbert

Bibliography

Davis, M. (1992). The role of the amygdala in fear and anxiety. Annual Review of Neuroscience, 15, 353–75.
Le Doux, J. E. (1995). Emotion: clues from the brain. Annual Review of Psychology, 46, 209–35.
LeDoux, J. E. (1998). The emotional brain. Weidenfeld and Nicolson, London.


See also conditioning; peptides; membrane receptors; stress.

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COLIN BLAKEMORE and SHELIA JENNETT. "anxiety." The Oxford Companion to the Body. 2001. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

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Anxiety and anxiety disorders

Anxiety and anxiety disorders

Definition

Anxiety is an unpleasant emotion triggered by anticipation of future events, memories of past events, or ruminations about the self.

Description

Stimulated by real or imagined dangers, anxiety afflicts people of all ages and social backgrounds. When the anxiety results from irrational fears, it can disrupt or disable normal life. Some researchers believe anxiety is synonymous with fear, occurring in varying degrees and in situations in which people feel threatened by some danger. Others describe anxiety as an unpleasant emotion caused by unidentifiable dangers or dangers that, in reality, pose no threat. Unlike fear, which is caused by realistic, known dangers, anxiety can be more difficult to identify and to alleviate.

Rather than attempting to formulate a strict definition of anxiety, most psychologists simply make the distinction between normal anxiety and neurotic anxiety, or anxiety disorders. Normal (sometimes called objective) anxiety occurs when people react appropriately to the situation causing the anxiety. For example, most people feel anxious on the first day at a new job for any number of reasons. They are uncertain how they will be received by coworkers, they may be unfamiliar with their duties, or they may be unsure they made the correct decision in taking the job. Despite these feelings and any accompanying physiological responses, they carry on and eventually adapt. In contrast, anxiety that is characteristic of anxiety disorders is disproportionately intense. Anxious feelings interfere with a person's ability to carry out normal or desired activities. Many people experience stage frightthe fear of speaking in public in front of large groups of people. There is little, if any, real danger posed by either situation, yet each can stimulate intense feelings of anxiety that can affect or derail a person's desires or obligations. Sigmund Freud described neurotic anxiety as a danger signal. In his id-ego-superego scheme of human behavior, anxiety occurs when unconscious sexual or aggressive tendencies conflict with physical or moral limitations.

According to a standard manual for mental health clinicians, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revised (also known as the DSM-IV-TR ), the following disorders are considered anxiety disorders:

  • Panic disorder without agoraphobiaA person with this disorder suffers from recurrent panic attacks and worries about experiencing more attacks, but agoraphobia is not present. Panic attacks are sudden attacks of intense fear or apprehension during which the sufferer may experience shortness of breath, increased heart rate, choking, and/or a fear of losing control. Agoraphobia is anxiety about places or situations from which escape might be difficult, or in which help might not be available.
  • Panic disorder with agoraphobiaA person with this disorder also experiences recurrent panic attacks but also has agoraphobia. The anxiety about certain places or situations may lead to avoidance of those places or situations.
  • Agoraphobia without history of panic disorderThe person with this disorder suffers from agoraphobia and experiences panic-like symptoms but does not experience recurring panic attacks.
  • Specific phobias A person diagnosed with a specific phobia suffers from extreme anxiety when he or she is exposed to a particular object or situation. The feared stimuli may include: particular animals (dogs, spiders, snakes, etc.), situations (crossing bridges, driving through tunnels), storms, heights, and many others.
  • Social phobiaA person with social phobia fears social situations or situations in which the individual is expected to perform. These situations may include eating in public or speaking in public, for example.
  • Obsessive-compulsive disorder A person with this disorder feels anxiety in the presence of a certain stimulus or situation, and feels compelled to perform an act (a compulsion ) to neutralize the anxiety. For example, upon touching a doorknob, a person may feel compelled to wash his or her hands four times, or more.
  • Post-traumatic stress disorder This disorder may be diagnosed after a person has experienced a traumatic event, and long after the event, the person still mentally re-experiences the event along with the same feelings of anxiety that the original event produced.
  • Acute stress disorder Disorder with similar symptoms to post-traumatic stress disorder, but is experienced immediately after the traumatic event. If this disorder persists longer than one month, the diagnosis may be changed to post-traumatic stress disorder.
  • Generalized anxiety disorder A person who has experienced six months or more of persistent and excessive worry and anxiety may receive this diagnosis.
  • Anxiety due to a general medical conditionAnxiety that the clinician deems is caused by a medical condition.
  • Substance-induced anxiety disorderSymptoms of anxiety that are caused by a drug, a medication, or a toxin.
  • Anxiety disorder not otherwise specifiedThis diagnosis may be given when a patient's symptoms do not meet the exact criteria for each of the above disorders as specified by DSM-IV-TR.

Resources

BOOKS

Amen, Daniel G. Change Your Brain, Change Your Life: The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger, and Impulsiveness. New York: Crown Publishing Group, 2000.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition, text revised. Washington DC: American Psychiatric Association, 2000.

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anxiety

anxiety, anticipatory tension or vague dread persisting in the absence of a specific threat. In contrast to fear, which is a realistic reaction to actual danger, anxiety is generally related to an unconscious threat. Physiological symptoms of anxiety include increases in pulse rate and blood pressure, accelerated breathing rates, perspiration, muscular tension, dryness of the mouth, and diarrhea. Freud postulated that anxiety was a result of repressed, pent-up sexual energy, but later came to view it as a danger signal alerting the ego to excessive stimulation and causing repression. Anxiety disorders include observable, overt anxiety, as well as phobias and other conditions where a defense mechanism has been set up to disguise the anxiety from both the sufferer and the observer. In generalized anxiety, the individual experiences long-term anxiety with no explanation for its cause; such a condition may be called free-floating, since it is not linked to a specific stimulus. Panic disorder involves sudden anxiety attacks which are manifested in heart palpitations, shortness of breath, or fainting. The individual with a phobic disorder can identify the stimulus that causes anxiety: such stimuli as enclosed space, heights, and crowds become imbued with greatly exaggerated anxiety and are carefully avoided by the phobic individual. Obsessive-compulsive disorders (OCD) are characterized by obsessions (mental quandries) and compulsions (physical actions) that engage the individual excessively. Extreme anxiety may be experienced if the person does not carry out the compulsion or attempts to ignore the obsession. Post-traumatic stress disorder occurs when an individual has recurrent dreams, flashbacks, or panic attacks after a particularly traumatic experience.

See D. F. Klein, Anxiety (1987); D. H. Barlow, Anxiety and Its Disorders (1988); S. J. Rachman, Fear and Courage (1990).

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Anxiety

ANXIETY

Anxiety refers to an unpleasant emotional state, a response to anticipated threat or to specific psychiatric disorders. In anxiety, the anticipated threat is often imagined. Anxiety consists of physiological and psychological features. The physiological symptoms can include breathing difficulties (hyperventilation, shortness of breath), palpitations, sweating, light-headedness, diarrhea, trembling, frequent urination, and numbness and tingling sensations. The anxious person is usually hypervigilant and startles easily. The subjective psychological experience of anxiety is characterized by feelings of apprehension or fear of losing control, depersonalization and derealization, and difficulties in concentration. Strains around the performance of social roles (e.g., spouse, parent, wage earner) and certain life situations (e.g., separating from parents when starting school or leaving home, illness) can generate anxiety symptoms. Other factors can contribute to the etiology of anxiety, such as use of alcohol, caffeine and other stimulant drugs (e.g., amphetamine), a family history of anxiety symptoms, or a biological predisposition. In certain cases, recurrent anxiety symptoms will lead an individual to avoid certain situations, places, or things (phobias). In many cases, an anxious emotional state can motivate positive coping behaviors (e.g., anxiety that leads to studying for an exam). When the anxiety becomes excessive and impairs functioning, it can lead to the development of psychiatric illness. Individuals differ in their predisposition to anxiety.

Different constellations of anxious mood, physical symptoms, thoughts, and behaviors, when maladaptive, constitute various anxiety disorders. Panic disorder is characterized by brief, recurrent, anxiety attacks during which individuals fear death or losing their mind and experience intense physical symptoms. People with obsessive compulsive disorder experience persistent thoughts that they perceive as being senseless and distressing (obsessions) and that they attempt to neutralize by performing repetitive, stereotyped behaviors (compulsions). The essential feature of phobic disorders (e.g., agoraphobia, social phobia, simple phobia) is a persistent fear of one or more situations or objects that leads the individual to either avoid the situations or objects or endure exposure to them with great anxiety. Generalized anxiety disorder is diagnosed in individuals who persistently and excessively worry about several of their life circumstances and experience motor tension and physiologic arousal. Anxiety disorders are the psychiatric illness most frequently found in the general population.

Anxiety states can result from underlying medical conditions, and therefore these conditions should always be looked for when evaluating problematic anxiety. When anxiety develops into a psychiatric illness, various forms of treatment are available to reduce it. The choice of treatment often depends on the specific disorder. Medications may be used, including anxiolytics (e.g., Benzodiazepines, buspirone) and Antidepressants (e.g., imipramine, fluoxetine). Psychotherapies offered generally consist of cognitive-behavioral interventions (e.g., exposure therapy), but they can include psychotherapy of a supportive nature or more psychodynamically oriented approaches. Some people with severe anxiety may turn to alcohol or nonprescribed sedative-hypnotics for symptom relief, and this in turn may exacerbate the underlying condition.

(See also: Causes of Substance Abuse: Psychological (Psychoanalytic) Perspective: Prescription Drug Abuse )

BIBLIOGRAPHY

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Press.

Brawman-Mintzer, O., & Lydiard, R. B. (1997). Generalized anxiety disorder. In A. Tasman, G. Kay, & J. A. Lieberman (Eds.), Psychiatry, 1st edition (pp. 1100-1118). Philadelphia, PA: W. B. Saunders Company.

Shear, M. K. (1997). Panic disorder with and without agoraphobia. In A. Tasman, G. Kay, & J. A. Lieberman (Eds.), Psychiatry, 1st edition (pp. 1020-1036). Philadelphia, PA: W. B. Saunders Company.

Myroslava Romach

Karen Parker

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ROMACH, MYROSLAVA; PARKER, KAREN. "Anxiety." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Retrieved July 26, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3403100063.html

Anxiety and Anxiety Disorders

Anxiety and Anxiety Disorders

What Are Anxiety Disorders?

What Causes Anxiety Disorders?

What Are the Symptoms of Anxiety Disorders?

How Are Anxiety Disorders Diagnosed and Treated?

Resources

Anxiety (ang-ZY-e-tee) is a feeling of fear, worry, or nervousness that occurs for no apparent reason. Anxiety disorders are conditions in which anxiety becomes so intense and long-lasting that it causes serious distress, and may lead to problems at home, school, or work.

KEYWORDS

for searching the Internet and other reference sources

Generalized anxiety disorder

Obsessive-compulsive disorder

Panic disorder

Phobias

Separation anxiety disorder

Anxiety Attack

The percentage of people in the United States affected by anxiety disorders during a one-year period:

  • all anxiety disorders: 13 percent
  • phobias: 8 percent
  • post-traumatic stress disorder: 4 percent
  • generalized anxiety disorder: 3 percent
  • obsessive-compulsive disorder: 2 percent
  • panic disorder: 2 percent

These figures add up to more than 13 percent because some people have more than one kind of anxiety disorder.

On the first day of ninth grade, when Michelle started high school, she suddenly felt dizzy, sweaty, and short of breath when she walked down the hall toward her locker. For a few minutes, everything around her seemed strangely unreal. At first, Michelle thought it was just a little case of nerves. However, when the feelings returned the next day and the next, Michelle began to fear that she was losing control of her mind or that she had some terrible physical illness. In fact, Michelle was suffering from an anxiety disorder.

What Are Anxiety Disorders?

Everybody feels a little nervous now and then. Their palms may get sweaty when they take an important test, their heart may pound as they wait for the opening kickoff of a big game, or they may have butterflies in their stomach as they get ready for a first date. These feelings are perfectly normal. People with anxiety disorders, however, feel afraid, worried, or nervous even when there is no clear reason. Their feelings are intense and long lasting, and they may get worse over time. The feelings are very distressing to a person experiencing them, and can be so overwhelming that they can cause serious problems at home, school, or work.

Anxiety disorders are the most common of all mental disorders. All told, some type of anxiety disorder affects more than 19 million people in the United States. There are several different types of anxiety disorders.

Generalized anxiety disorder

Generalized anxiety is a term for constant, intense worry and stress over a variety of everyday events and situations. People who experience generalized anxiety always expect the worst to happen, even when there is no real reason for thinking this way. For example, they may worry all the time about their grades or sports performance, even when they are successful students or athletes. They may worry about loved ones, about the future, school, health, safety, or upsetting things they imagine could happen. These feelings may be accompanied by physical symptoms, such as tiredness, chest pain, trembling, tight muscles, headache, or upset stomach. When someone has experienced these symptoms for 6 months or longer, a mental health professional uses the diagnosis generalized anxiety disorder to describe their condition.

Separation anxiety disorder

Separation anxiety is the normal fear that babies and young children feel when they are separated from their parents or approached by strangers. It is not uncommon for children to have mild separation anxiety on the first day of school in kindergarten or first grade, or the first day of overnight camp. Usually, this feeling goes away after a few days as a child gets used to a new situation, new friends, and new adults in charge. For most children, separation anxiety lessens with age and experience. In some children, however, this normal fear turns into separation anxiety disorder, which is extreme fearfulness anytime the children are away from their parents or home. Children with this disorder may call their parents at work often, be afraid to sleep over at friends houses, or suffer extreme homesickness at camp. Separation anxiety disorder can result in frequent absences from school and avoidance of participation in normal social activities of childhood that involve being without their parents. Children with separation anxiety disorder tend to worry and they may be very afraid that their parents will get sick or be injured, or they may have frequent nightmares about getting lost.

Separation anxiety can carry over into the teenage years as well. Teenagers with separation anxiety may be uneasy about leaving home, and they sometimes start refusing to go to school. Extreme separation anxiety may be triggered by a change in school, or it may occur after a stressful event at home, such as a divorce, illness, or death in the family.

Panic disorder

Panic disorder is a disorder that involves repeated attacks of intense fear that strike often and without warning. People having a panic attack may feel as if things are unreal, or they may fear that they are going to die. Along with the fear, they may have physical symptoms, such as chest pain, a pounding heart, shortness of breath, dizziness, or an upset stomach.

Obsessive-compulsive disorder

Obsessive-compulsive (ub-SESiv-kum-PUL-siv) disorder (OCD) is a condition in which people become trapped in a pattern of repeated, unwanted, upsetting thoughts, called obsessions (ob-SESH-unz), and behaviors, called compulsions (kom-PULshunz). The thoughts or behaviors seem impossible to control or stop. Examples of common obsessions include worrying constantly about germs, whether the house is locked, and if a loved one is safe. Examples of common compulsions include washing the hands repeatedly, checking the door lock over and over again, and saying something over and over to keep a person safe.

Nothing to Fear

Not every fear is a phobia. Fears are not considered phobias unless they cause long-lasting, serious problems. Many fears are typical at different times of development. Common normal fears include:

  • birth to 6 months: loss of physical support (fear of falling), loud noises, large fast-approaching objects, or sudden movement
  • 7 to 12 months: strangers
  • 1 to 5 years: loud noises, storms, animals, darkness, separation from parents
  • 3 to 5 years: monsters, ghosts
  • 6 to 12 years: injury, burglars, being sent to the principal, punishment, failure
  • 12 to 18 years: tests in school, embarrassment

Phobias

Phobias (FO-bee-uhz) are unrealistic, long-lasting fears of some object or situation. The fear can be so intense that people go to great lengths to avoid the object of their dread. There are three types of phobia problems that mental health professionals may diagnose. They are specific phobias, social phobia (also called social anxiety disorder), and agoraphobia (AG-or-uh-FO-bee-uh). People with specific phobias have an intense fear of specific objects or situations that pose little real threat, such as dogs, spiders, storms, water, or heights. People with social phobia have an extreme fear of being judged harshly, embarrassed, or criticized by others, which leads them to avoid social situations. People with agoraphobia are terrified of having a panic attack in a public situation from which it would be hard to escape, such as standing in a crowd. If left untreated, the anxiety can become so severe that people might refuse to leave the house.

Post-traumatic stress disorder

Post-traumatic stress disorder involves long-lasting symptoms that occur after people have been through an extremely stressful, life-threatening event, such as a rape, mugging, child abuse, tornado, or car crash. People with the disorder may relive the traumatic event again and again in strong memories or nightmares. They may have other symptoms such as depression*, anger, crankiness, and a lack of normal emotions, and they may be easily startled, unusually fearful, and have trouble paying attention.

* depression
(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

What Causes Anxiety Disorders?

Genetics

There are probably several causes for anxiety disorders. Genetics may play a role in some cases. For example, research has shown that a twin is more likely to have obsessive-compulsive disorder if the other twin has it and if they are identical twins (twins that have identical genes*) rather than if they are fraternal twins (twins that do not have identical genes). Other twin studies have found a genetic component to panic disorder and social anxiety disorder.

* genes
are chemicals in the body that help determine a persons characteristics, such as hair or eye color. They are inherited from a persons parents and are contained in the chromosomes found in the cells of the body.

Brain circuits

Some research has focused on pinpointing the exact brain areas and circuits involved in anxiety and fear, which are at the root of anxiety disorders. Scientists have shown that, when faced with danger, the body sends two sets of signals to different parts of the brain. One set goes straight to the amygdala (uh-MIG-duh-luh), a small structure deep inside the brain, which sets the bodys automatic fear response in motion. This response readies the body to react to the threat. The heart starts to pound and send more blood to the muscles for quick action, while stress hormones and extra blood sugar are sent into the bloodstream to provide extra energy. The other set of signals takes a roundabout route to the cerebral cortex (suh-REE-brul KOR-teks), the thinking part of the brain. Thus, the body response is set in motion before the brain understands just what is wrong. As a built-in safety measure, this learned response is etched on the amygdala so the response will be quickly available for the next dangerous situation.

In people with anxiety disorders, an experience that feels scary, even one involving a normally safe object or situation, can create a deeply etched memory of fear. This memory can lead to the automatic physical symptoms of anxiety when the object or situation is experienced again. These symptoms, in turn, can make it hard to focus on anything else. Over time, people may start to feel anxiety in many situations. Studies have shown that memories stored in the amygdala may be hard to erase. However, people can gain control over their responses with experience and sometimes with psychotherapy*.

* psychotherapy
(sy-ko-THER-apee), or mental health counseling, involves talking about feelings with a trained professional. The counselor can help the person change thoughts, actions, or relationships that play a part in the illness.

Temperament

Another factor to take into account is a personality quality called temperament. Temperament refers to a persons inborn nature that consists of certain behavioral traits. To some extent, peoples tendency to be shy or nervous may be inborn, simply part of their nature. Some research suggests that babies who are easily upset never fully learn how to soothe themselves early in life the way other children with calmer temperaments do. They may react more strongly to stressful or anxiety-provoking situations than people whose temperament makes them more adaptable. Some experts believe that people with an inhibited, cautious temperament may be more likely to have problems with anxiety.

Life experiences

Yet another factor that plays a role in some anxiety disorders is stress, especially when it occurs early in life. Scientists have found that when rat pups are separated from their mothers at an early age they have a much greater startle response to later stressful situations than rat pups that were not separated. In addition to separation from a parent, human children may be affected by stressful situations such as child abuse, family violence, or growing up in an unsafe neighborhood. Unsafe conditions or frightening experiences may teach children to be overcautious, to expect bad things, or to worry excessively about possible dangers. People with low self-esteem* also may be prone to developing anxiety disorders.

* self-esteem
is the value that people put on the mental image that they have of themselves.

What Are the Symptoms of Anxiety Disorders?

The fear response associated with all of the anxiety disorders can involve a number of physical symptoms. These include:

  • pounding or racing heart
  • sweating
  • trembling
  • shortness of breath
  • choking feeling chest pain
  • upset stomach
  • stomachache
  • dizziness
  • faintness
  • numbness
  • tingling
  • chills

Anxiety disorders also can lead to changes in the way a person feels, thinks, or behaves. For example, people with anxiety disorders might:

  • feel afraid and nervous
  • fear they are losing control or going crazy
  • fear they will die or get hurt
  • worry about a parents injury or illness
  • worry about being away from home
  • worry about things before they happen
  • worry constantly about school or sports
  • refuse to go to school
  • be afraid to meet or talk to new people
  • avoid new situations
  • have trouble sleeping due to worry or fear

Without treatment, people may be driven to take extreme measures to avoid situations that trigger these unpleasant symptoms. They may refuse to join in many activities. Relationships with family and friends may suffer as a result. In addition, people who are always thinking about fears and worries are unable to concentrate on school, work, or sports. They may fail to do as well as they could in these areas.

How Are Anxiety Disorders Diagnosed and Treated?

Anxiety disorders often occur along with other mental disorders, such as depression, eating disorders*, or substance abuse*. They also may accompany physical illnesses. In such cases, these other disorders also must be treated. People with the symptoms of an anxiety disorder need a complete medical checkup to rule out other illnesses. They also need a

* eating disorders
are conditions in which a persons eating behaviors and food habits are so unbalanced that they cause physical and emotional problems.
* substance abuse
is the misuse of alcohol, tobacco, illegal drugs, prescription drugs, and other substances such as paint thinners or aerosol gases that change how the mind and body work.

thorough psychological evaluation. The mental health professional will ask about symptoms and the problems that they cause. With children and teenagers, the professional generally will also talk to parents or even teachers.

Self-injury and other behaviors that seem impossible to control are signs of an anxiety disorder. Cognitive-behavioral therapy and medication can help people learn how to change unwanted behaviors like cutting (intentionally cutting ones own skin with a blade or other sharp object), shown here, and how to create new ways of thinking about themselves and the stresses they encounter in their daily lives. Photo Researchers, Inc.

Medications

Medications cannot cure anxiety disorders, but they can be very helpful for relieving symptoms. Several kinds of medications are used to treat anxiety. Although these medications work well, they can be very dangerous if mixed with alcohol, and some can be habit forming. Increasingly, antidepressant medications originally developed to treat depression are becoming the more commonly prescribed anti-anxiety medicines as well. Finding the right medication and dose for a given person can take some time. Fortunately, though, if one medication does not work, there are several others that can be prescribed.

Psychotherapy

Medications often are combined with psychotherapy, in which people talk about their feelings, experiences, and beliefs with a mental health professional. In therapy, a person can learn how to change the thoughts, actions, or relationships that play a part in their problems. There are many kinds of psychotherapy, but two kinds have been shown to work particularly well in treating anxiety disorders: cognitive (COG-nih-tiv) therapy and behavioral (be-HAY-vyor-ul) therapy. Often techniques from these two types of therapy are combined.

Behavioral techniques help people replace specific, unwanted behaviors with healthier behaviors. Behavioral approaches that may be used to treat anxiety include relaxation training and deep breathing, for example. People are taught to take slow, deep breaths to relax, because people with anxiety often take fast, shallow breaths that can trigger other physical symptoms, such as a racing heart and dizziness. Another behavioral technique, called exposure (ek-SPO-zhur) therapy, gradually brings people into contact with a feared object or situation so they can learn to control their fear response to what frightens them.

Cognitive-behavioral therapy helps people understand and change their thinking patterns so they can learn to react differently to situations that cause anxiety. This awareness of thinking patterns is combined with behavioral techniques. For example, someone who becomes dizzy during panic attacks and fears he is going to die may be asked to spin in a circle until he gets dizzy. When he becomes alarmed and starts thinking, Im going to die, he learns to replace that thought with another one, such as Its just dizziness. I can handle it. Though anxiety disorders can be extremely distressing to those experiencing them, the good news is that these disorders respond very well to treatment.

See also

Agoraphobia

Fears

Obsessive-Compulsive Disorder

Panic

Phobias

Post-Traumatic Stress Disorder

School Avoidance

Stress

Therapy

Resources

Book

Bourne, Edmund J. The Anxiety and Phobia Workbook. Oakland, CA: New Harbinger Publications, 1995.

Organizations

Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. This group is for people with a personal or professional interest in anxiety disorders. Telephone 301-231-9350 http://www.adaa.org

Anxiety Disorders Education Program, U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This government program provides a wide range of information about anxiety disorders. Telephone 888-8ANXIETY http://www.nimh.nih.gov/anxiety

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"Anxiety and Anxiety Disorders." Complete Human Diseases and Conditions. 2008. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

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"Anxiety and Anxiety Disorders." Complete Human Diseases and Conditions. 2008. Retrieved July 26, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3497700043.html

anxiety

anx·i·e·ty / angˈzī-itē/ • n. (pl. -ties) a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome. ∎  desire to do something, typically accompanied by unease: the housekeeper's eager anxiety to please. ∎  Psychiatry a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks.

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"anxiety." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

"anxiety." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. (July 26, 2016). http://www.encyclopedia.com/doc/1O999-anxiety.html

"anxiety." The Oxford Pocket Dictionary of Current English. 2009. Retrieved July 26, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-anxiety.html

anxiety

anxiety (ang-zy-iti) n. generalized pervasive fear. a. disorder any one of a group of mental or behavioural disorders in which anxiety dominates the patient's life or is experienced in particular situations. See generalized anxiety disorder, neurosis, panic disorder, post-traumatic stress disorder.

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"anxiety." A Dictionary of Nursing. 2008. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

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"anxiety." A Dictionary of Nursing. 2008. Retrieved July 26, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O62-anxiety.html

anxiety

anxietybanditti, bitty, chitty, city, committee, ditty, gritty, intercity, kitty, nitty-gritty, Pitti, pity, pretty, shitty, slitty, smriti, spitty, titty, vittae, witty •fifty, fifty-fifty, nifty, shifty, swiftie, thrifty •guilty, kiltie, silty •flinty, linty, minty, shinty •ballistae, Christie, Corpus Christi, misty, twisty, wristy •sixty •deity, gaiety (US gayety), laity, simultaneity, spontaneity •contemporaneity, corporeity, femineity, heterogeneity, homogeneity •anxiety, contrariety, dubiety, impiety, impropriety, inebriety, notoriety, piety, satiety, sobriety, ubiety, variety •moiety •acuity, ambiguity, annuity, assiduity, congruity, contiguity, continuity, exiguity, fatuity, fortuity, gratuity, ingenuity, perpetuity, perspicuity, promiscuity, suety, superfluity, tenuity, vacuity •rabbity •improbity, probity •acerbity • witchetty • crotchety •heredity •acidity, acridity, aridity, avidity, cupidity, flaccidity, fluidity, frigidity, humidity, hybridity, insipidity, intrepidity, limpidity, liquidity, lividity, lucidity, morbidity, placidity, putridity, quiddity, rabidity, rancidity, rapidity, rigidity, solidity, stolidity, stupidity, tepidity, timidity, torpidity, torridity, turgidity, validity, vapidity •commodity, oddity •immodesty, modesty •crudity, nudity •fecundity, jocundity, moribundity, profundity, rotundity, rubicundity •absurdity • difficulty • gadgety •majesty • fidgety • rackety •pernickety, rickety •biscuity •banality, duality, fatality, finality, ideality, legality, locality, modality, morality, natality, orality, reality, regality, rurality, tonality, totality, venality, vitality, vocality •fidelity •ability, agility, civility, debility, docility, edibility, facility, fertility, flexility, fragility, futility, gentility, hostility, humility, imbecility, infantility, juvenility, liability, mobility, nihility, nobility, nubility, puerility, senility, servility, stability, sterility, tactility, tranquillity (US tranquility), usability, utility, versatility, viability, virility, volatility •ringlety •equality, frivolity, jollity, polity, quality •credulity, garrulity, sedulity •nullity •amity, calamity •extremity • enmity •anonymity, dimity, equanimity, magnanimity, proximity, pseudonymity, pusillanimity, unanimity •comity •conformity, deformity, enormity, multiformity, uniformity •subcommittee • pepperminty •infirmity •Christianity, humanity, inanity, profanity, sanity, urbanity, vanity •amnesty •lenity, obscenity, serenity •indemnity, solemnity •mundanity • amenity •affinity, asininity, clandestinity, divinity, femininity, infinity, masculinity, salinity, trinity, vicinity, virginity •benignity, dignity, malignity •honesty •community, immunity, importunity, impunity, opportunity, unity •confraternity, eternity, fraternity, maternity, modernity, paternity, taciturnity •serendipity, snippety •uppity •angularity, barbarity, bipolarity, charity, circularity, clarity, complementarity, familiarity, granularity, hilarity, insularity, irregularity, jocularity, linearity, parity, particularity, peculiarity, polarity, popularity, regularity, secularity, similarity, singularity, solidarity, subsidiarity, unitarity, vernacularity, vulgarity •alacrity • sacristy •ambidexterity, asperity, austerity, celerity, dexterity, ferrety, posterity, prosperity, severity, sincerity, temerity, verity •celebrity • integrity • rarity •authority, inferiority, juniority, majority, minority, priority, seniority, sonority, sorority, superiority •mediocrity • sovereignty • salubrity •entirety •futurity, immaturity, impurity, maturity, obscurity, purity, security, surety •touristy •audacity, capacity, fugacity, loquacity, mendacity, opacity, perspicacity, pertinacity, pugnacity, rapacity, sagacity, sequacity, tenacity, veracity, vivacity, voracity •laxity •sparsity, varsity •necessity •complexity, perplexity •density, immensity, propensity, tensity •scarcity • obesity •felicity, toxicity •fixity, prolixity •benedicite, nicety •anfractuosity, animosity, atrocity, bellicosity, curiosity, fabulosity, ferocity, generosity, grandiosity, impecuniosity, impetuosity, jocosity, luminosity, monstrosity, nebulosity, pomposity, ponderosity, porosity, preciosity, precocity, reciprocity, religiosity, scrupulosity, sinuosity, sumptuosity, velocity, verbosity, virtuosity, viscosity •paucity • falsity • caducity • russety •adversity, biodiversity, diversity, perversity, university •sacrosanctity, sanctity •chastity •entity, identity •quantity • certainty •cavity, concavity, depravity, gravity •travesty • suavity •brevity, levity, longevity •velvety • naivety •activity, nativity •equity •antiquity, iniquity, obliquity, ubiquity •propinquity

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"anxiety." Oxford Dictionary of Rhymes. 2007. Encyclopedia.com. 26 Jul. 2016 <http://www.encyclopedia.com>.

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