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Anxiety

GRACE PALEY
1985

INTRODUCTION
AUTHOR BIOGRAPHY
PLOT SUMMARY
CHARACTERS
THEMES
STYLE
HISTORICAL CONTEXT
CRITICAL OVERVIEW
CRITICISM
SOURCES
FURTHER READING

INTRODUCTION

Grace Paley's short story "Anxiety" was originally published in her third collection of short stories, Later the Same Day, in 1985. More recently, "Anxiety" was included in a compilation of her short stories, Grace Paley: The Collected Stories, published in 1994. Paley's short stories depict the lives and experiences of men and women living in New York City. Initially Paley's work captured the experiences of Russian- and Yiddish-speaking Jewish immigrants and the language of the community in which she was raised. Her later work was more feminist in tone and reflected Paley's commitment to the equal rights movement. As she became more feminist, Paley focused more on depicting the conflicts and trials of ordinary women trying to survive in a world designed for men's successes. The stories in Later the Same Day begin to move away from feminism and focus more clearly on Paley's antiwar interests, her pacifism, and her concerns for the future of the world. "Anxiety" fits well into Paley's later literary tradition of protest literature. The story's protagonist is a woman who worries so much about the possible destruction of the world that she accosts people walking on the street to warn them that the danger they face is so severe that they cannot ignore it even long enough to enjoy a moment of happiness. Paley's work, then, reflects the social shift from the 1950s ideal of women supporting a man's world to the women's movement of the

1970s, and finally to the image of women as voices of caution and warning about the dangers that the world faces.

AUTHOR BIOGRAPHY

Grace Paley was born Grace Goodside on December 11, 1922, in New York City. Her father, Zenya Gutseit (later changed to Isaac Goodside), was a Russian Jew who immigrated to the United States in 1905 in the wave of Eastern European and Russian Jews who came to the United States at the turn of the century to escape the ethnic violence that plagued the Jews of that region. Paley's father attended medical school and became a doctor, while her mother, Manya (later changed to Mary), worked as a photography retoucher and managed her husband's medical practice on the first floor of the family home in the Bronx. Paley grew up in the same building that housed her father's medical office. She was part of an extended family of aunts and grandmothers, consisting of multiple generations, all under the same roof. She was also raised in the family tradition of socialists and anarchists, many of whom had died in Russia for their beliefs. Those who survived and came to the United States brought their willingness to protest. Paley was the youngest of three children, all of whom grew up speaking Russian, Yiddish, and English in a household with two cultures, the old and the new. Paley attended Hunter College (1938-39), and at age nineteen, she married Jess Paley, who was then sent overseas to fight in World War II. After he returned from the war, they had two children, Nora in 1949 and Daniel in 1951. Paley attended New York University briefly in the late 1940s but never completed a program of study. Paley also studied poetry with W. H. Auden in the early 1950s.

Paley began writing poetry and fragments of stories as a small child, but her first completed stories did not emerge until the 1950s. An initial three stories were shown to a family friend and editor, who asked Paley to write more stories, which he would later publish as her first collection of short stories, The Little Disturbances of Man: Stories of Women and Men at Love (1959). These first stories were considered significant enough that Paley was awarded a Guggenheim Fellowship in 1961 and a National Endowment for the Arts Award in 1966. After the publication of this first slim volume of stories, Paley turned her attention to the Vietnam War. As the youngest child by fourteen years, she had grown up in the company of adults. Paley absorbed her extended family's commitment to social concerns and was arrested several times as she protested on behalf of the antiwar organizations to which she belonged, including the War Resisters' League, Resist, the Women's Pentagon Action, and the Greenwich Village Peace Center. Paley and her husband divorced in 1971. In 1972, she married poet and playwright Robert Nichols.

A second collection of Paley's short stories, Enormous Changes at the Last Minute, was published in 1974. Her third collection of stories, Later the Same Day (1985), in which "Anxiety" first appeared, earned Paley the honor of being named the first State Author of New York in 1986. In addition to the three books of short stories, Paley was also writing poetry, and in 1985, her first collection of poems, Leaning Forward, was published.

Paley was honored with the Edith Wharton Award in 1983 and a National Endowment for the Arts Senior Fellowship in 1987. She was also elected to the American Academy of Arts and Letters. In 1989, Paley retired from Sarah Lawrence College, where she had been teaching writing since 1966. Long Walks and Intimate Talks, a collection of short stories and poetry, followed in 1991. In 1993, Paley received the Rea Award for the Short Story, considered to be the highest honor awarded to short story writers. Throughout her writing career, Paley frequently published short pieces in magazines, in newspapers, and in the occasional newsletter. A collection of these short essays and columns was published as Just as I Thought in 1998. Paley died August 22, 2007, at her home in Thetford Hills, Vermont, of breast cancer.

PLOT SUMMARY

"Anxiety" begins with a woman's observance of two fathers waiting for their children to emerge from school at the end of the day. The setting is spring, and the woman who watches the two fathers mentions that her window box contains greenhouse marigolds. The woman is so anxious for spring that she has planted the first hothouse blooms of the season at her window. It is also one of the first days nice enough to open a window and watch people walking along the streets. The window box partially hides her face, as she watches "through the ferny leaves."

When the bell rings the children rush through the doors to their waiting fathers. When one of the two fathers lifts his daughter to his shoulders, the watching woman notes that the child appears to be Chinese, or at least "a little" Chinese. The father was earlier described as having curly hair, which suggests that the little girl is of mixed heritage, since Asians do not often have curly hair. Paley uses this subtle piece of information to remind her readers that New York City is a mixture of different ethnicities. The second father also lifts his child, a son, onto his shoulders, but Paley has provided only a minimal description of this father, stating that he is physically similar to the first father. His child is not described at all.

As the two fathers and children begin walking away from the school, they pass under the window of the woman who has watched them walked from the school. She observes that the father of the little girl appears to be struggling with his daughter. He is slight and perhaps too frail to carry his daughter on his shoulders. The little girl wiggles and the father's discomfort leads him to tell the child to stop her wiggling. The child responds with "Oink oink." When challenged, she repeats the two words. The father, now clearly angry, grabs the child and sets her on the ground. The movement is hard enough that the little girl rubs her ankle, which now hurts. When she asks what she has done to anger him, he yells that she is to hold his hand.

At this point, the woman ceases to watch from between the leaves and now leans out the window and interjects herself into the tableau unfolding on the street. She echoes the man's agitation as she yells at him, "Stop! Stop!" It is not clear if the woman wants the man to stop yelling at his daughter or to stop walking. Perhaps she means for both to happen. The man quickly turns around to look up at the speaker and ask who she is. The suggested meaning of his words is to ask who she is to yell at a complete stranger. In response, she finally moves the flowers that have hidden her and emerges to be clearly seen by the walkers below.

Once the father can see her, the woman invokes the tradition of tenement women, who have lived in similar buildings in generations past. These women have leaned out their windows and supervised their children below. Her memories of this tradition make her brave enough to tell the young father that the history of mothers in this building enables her to lean out the window and give him the traditional wisdom of mothers, who have always leaned out their windows to advise and chastise. The young father is a bit embarrassed to be called out by this older woman, and he jokes with his friend about the old gray-haired woman leaning out the window.

She asks him his age, and he replies that he is thirty-three. In response she tells him that he is a generation ahead of his father in his relationship with his daughter. His father's generation is a generation of fathers who worked to provide for their families and did not walk to school to pick up their children. These fathers saw a clearer division of male and female spheres. In this earlier generation, mothers cared for their children, and fathers worked to support their family. The lines that defined parenting roles were more clearly drawn.

The narrator knows that complimenting the father is one way to begin the conversation and put him at ease. She has more that she wants to say to him, so she leans even farther out the window to caution him about the danger that all humankind face. The gravity of her words is first illustrated by her need to lean farther out the window. She wants to get as close to the young father as is possible when she tells him that "madmen intend to destroy this beautifully made planet." She warns him that the risk to his child and to other children needs to be a concern for all fathers. These words reflect a growing awareness that nuclear weapons, environmental pollution, and terrorism have the potential to destroy the world. At first, the father greets the woman's warnings with mockery, but he soon admits that he is also concerned about the future.

Now that she has the father's attention, the woman asks why he became so angry with his daughter that he slammed her to the ground. Once she is able to get the father to admit that it was the words "oink oink" that angered him, the old woman elicits the confession that hearing those two words reminded him of a time when he protested against the authority establishment and used those words. Now when those same words are directed toward him, he is reminded that he is over thirty and part of the establishment that he once held in derision. This realization defuses the young father's anger, as he recalls that, while he never wanted to be an authority figure, it has happened anyway. Fatherhood has made him a responsible member of society. The woman next suggests that the father should begin the walk again by returning to the school yard and pretending that he never lost his temper with his daughter.

Both fathers begin to pretend they are horses giving their children rides home. The little girl's father forgets his frailty, as his daughter cheerfully kicks his chest and screams, "giddap giddap." The fathers and children enjoy the moment of play as they gallop toward their homes. Only the old woman is not happy. She notices that they are galloping toward a very busy intersection and worries that they will not make it safely to their homes. After she closes the window, she sits and wonders how she can make sure that they will arrive home safely, with so many large cars, created as the "bulky dreams of automakers," putting their lives at risk. If they arrive home safely she would like to be certain that the children have a healthy snack of juice, milk, or cookies. The final brief paragraph of this short story serves to define the title "Anxiety." Readers finally grasp that this woman sees risk from her windows. She is like mothers everywhere who would like to protect all children from the risks they face in what has become an increasingly dangerous world.

CHARACTERS

Ken

Ken is one of only two characters whose names are mentioned in "Anxiety." His role is a minor one. He meets his son at school and carries the child on his shoulders until they are stopped by the woman's voice. Ken and his son accompany the other father and his daughter on the journey home. He has no important position in the story.

Rosie

Rosie is the child whose father is chastised by the woman watcher. Readers only learn of the child's name near the end of the story; for most of the story, she is identified as a giggling, playful child who wiggles too much. The first image of the child is one of happiness and joy, and thus the father's irritation that she is too playful is at first a bit surprising. His subsequent anger at the little girl's chanting "oink oink," which results in the child being forcibly set on the ground, is shocking. His anger seems to be an inappropriately severe reaction to the child's behavior. When the father finally admits that he was angry at the child because she was treating him as if he "was a figure of authority," his anger is defused and child's happiness is restored. The ease with which Rosie's mood is so quickly returned to joy suggests that the child's relationship with her father is filled with love. His momentary irritation is quickly forgotten, and Rosie easily and happily climbs back on her father's back to pretend that he is a horse giving her a ride home. At heart, she is a happy child, and the father's irritation with her seems to be nothing more than a momentary bad mood.

Woman Watcher

The woman who watches from the window is the narrator of "Anxiety." The only description given of her is that her hair is gray, so readers know that she is not a young woman and not as young as the father she accosts. She is at least a generation older. Readers know what is happening only from her perspective. She is also the voice of caution, of warning, and of fear. She worries that the young father is not patient with his child. She also worries that he is not appreciative of the present and does not cherish his daughter enough, since the future is so filled with risk. At the end of the story, she worries that he cannot get his daughter home safely past the busy intersection or beyond and "across other dangerous avenues."

She is like many mothers, who never stop worrying about their children, no matter how remote the danger. At first the woman seems to be only a concerned citizen who wants to stop a father from being short-tempered with his daughter, but at the end of the story, her worry extends to concern that the father might not be attentive enough to cross a busy intersection without calamity. Worry about busy intersections would seem justified if the small children were walking home on their own, but they are not. They are accompanied by their fathers, so when the woman worries about "how to make sure" that they will arrive home safely, she seems more inclined to worry than most mothers. She may also be lonely. Instead of being down on the street, she peeks out at the people on the street below, watching through the leaves of the plants in the window box. She is a watcher who observes life rather than participates in it.

The old woman is not given a name, although it is likely that she is Faith Darwin, who appears in many of Paley's stories. As she is unnamed, however, the woman becomes representative of a tradition of women who have leaned out of their tenement windows and watched their children at play on the streets below. From their windows, mothers could yell at their children to take care of a younger sibling or to come inside for dinner. Most important, these mothers could shout warnings to their children, just as the old woman now shouts at the young father who walks on the sidewalk below.

The streets used to be safer for children. There were fewer cars and the intersections were not so dangerous. There were also no threats from "the airy scary dreams of scientists," who create technologies that lead to environmental pollution or who create nuclear weapons and turn the world into a place where war threatens. Paley uses this woman's words as a way to remind readers that the world is not a safe place and that the future may be even more dangerous than the present.

Young Father

The young father is given no name, since he represents all fathers who need to be warned about the dangerous future their children face. This young father is described as being like other fathers. He and his friend are identified in the opening scene as identical. They both have curly hair and brown mustaches. They wait together, talking easily and eating pizza as they wait for their children to emerge from the school. He is like every other father who comes to the school to walk his child home. He assumes his own identity and individual characteristics on the journey home when he becomes upset with his daughter, who wiggles too much. At that point, Paley identifies him as frail. The wiggling child creates discomfort. He is uncomfortable enough with the child's weight on his shoulders that he becomes easily angered by the child's chanting "oink oink."

In response to being accosted by the woman in the window, the young father is a bit uncomfortable and embarrassed at having been caught being short-tempered with his daughter. Although he laughs at what the woman says, Paley describes him as doing so with a "little embarrassment." However, he quickly relaxes after the woman tells him that he is ahead of the previous generation in his treatment of his daughter. She is referring to the father's willingness to pick up his child from school. The previous generation of fathers did not do this; they worked at jobs all day, and mothers picked up the children.

The father's involvement with his daughter is a positive trait. By beginning with a compliment, the woman helps to diffuse the father's embarrassment and any anger he might feel at the woman interfering with his treatment of his child. The father does indicate that he is not completely accepting of what the woman tells him. He thinks the woman is being dogmatic and indicates this feeling when he tells her: "Speech, speech." However, he is interested enough in her remarks that he continues to stand and wait for her to continue speaking to him.

The young man's attentiveness validates the woman's concerns and indicates his own awareness of the precarious nature of the future of the world. He is clearly a concerned father who worries about his daughter's future. Paley makes the young man's concern evident when he turns a "serious face" to the woman and continues listening to her speak. The father also reveals a sense of humor when the woman contrives to force an admission from him that he had used "oink oink" to address policemen during a demonstration years earlier, which is why he reacted so strongly to his daughter's use of the phrase. As soon as the young father realizes the source of his anger, he is quick to try to make amends and suggests that he be the horse and his daughter be the rider on the way home. The father's love for his child is evident in the final scene of the two of them together, as they gallop off toward their home.

TOPICS FOR FURTHER STUDY

  • In previous generations, mothers would have been the parents most often waiting outside the school to walk their children home. When Paley is writing, however, fathers also share their children's walk home. Research the changes in women's employment since 1965. Look for statistics that reveal the number of women who were been employed outside the home in 1965, 1975, 1985, 1995, and 2005. Prepare an oral presentation that discusses the information that you have discovered. Be prepared to ask your classmates about their own home experiences and how their mother's employment is reflected in parenting roles in their homes.
  • Artists are often inspired by writers to create some of the most beautiful art imaginable. For instance, William Blake was inspired by John Milton's poetry to create illustrations of the poet's finest work. Spend some time looking through art books in the library and try to select a picture or illustration that you feel best illustrates Paley' short story. Then, in a carefully worded essay, compare the art that you have selected to the images that Paley creates in her story, noting the similarities and differences between art and prose.
  • Paley mentioned in interviews that as a child she was told stories, and as an adult she became the writer of stories. What do you see as the difference between telling stories and writing stories? Research the history of the oral narrative. Look for information about when the oral narrative was replaced by the written narrative and prepare an oral report in which you discuss the history of both narratives, what you think was lost and gained by the transition from spoken stories to written stories, and what you see as the essential differences between these two narrative styles.
  • One of Paley's concerns in this short story is the destruction of the planet. Research the role of the group Greenpeace and write an essay in which you analyze this group's work. What successes, if any, can attributed to their attempts to protect the planet from environmental destruction?
  • The narrator refers to a tradition of women who watched over their children from the tenement windows. Research life in New York City in 1915 and 1985. How did people live during these two periods? Where did they work? What did they do when they were not working? What were families like? Create a poster in which you list the similarities and the differences that you have found between these two eras.

THEMES

Anxiety

One important theme of Paley's short story "Anxiety" is taken directly from the title. Paley's protagonist is so anxious about the future that she sits and watches the world from her window. When she sees a father in need of a warning, she leans out of her window and speaks to him from the safety of her home. Initially it appears that the woman is only concerned about the father's harsh treatment of his daughter, but it quickly becomes apparent that the woman is mostly concerned about danger. The danger faced is not tangible or even defined. It is a vague danger in the future, with risks posed by madmen who "intend to destroy" the world. The woman warns the father that the risk for his child is sufficient that it should interfere with any pleasure that the father might be finding in his walk home with his daughter. Although her warning that they should not be finding any enjoyment in their lives seems excessive, even at this point of the narrative, the woman seems to be presenting reasonable fears about the dangers presented by war and the kinds of technology that creates weapons designed to destroy millions of people.

In the final two paragraphs, however, the true extent of her anxiety is revealed as a fear of the more vague possibilities of danger. As the children and their father leave to continue their journey home, she worries about the traffic at the intersection and then the intersections beyond the one at the corner. Finally, readers see that she even worries about the snack the children will eat when they return home, and she wishes that she could see that they are eating a healthy snack. Her anxiety about the world is severe enough that she needs to see that the children are safe and healthy. Of course, she cannot see them at their home, since like the hothouse marigolds, the woman is sheltered in her own home, safe from all the risks that lie outside her window.

Parental Love

Parental love is often described as unconditional and unlimited. Although children can occasionally test their parents' patience, most parents are able to quickly recover from momentary irritation, as the father in Paley's story does. Although the father becomes angry in the story, his love for his daughter is not in doubt. Because of his parental love, he seems to share the woman's concerns about the danger that children face when men try to "destroy this beautifully made planet." He also admits that he became angry because his child's words suggested that he was a figure of authority, which is not how he wants to be seen. Parental love is also about recognizing and acknowledging parental injustice. The brief conflict between the father and his child is resolved when he lifts her onto his back to continue their ride home. Both parent and child are enveloped in love as they alternate yelling "U-up" and "giddap" on their gallop home. In the face of an uncertain future, what this father can offer his child is evidence of his love for her.

Science and Technology

The warnings in "Anxiety" reflect the narrator's concern that humankind is not paying sufficient attention to the risks posed by science and technology. For example, the woman in the window warns the father that the futures of his child and of all children are in danger due to the actions of madmen, who are putting the world at risk. The exact risk is never defined. Making the risk vague allows Paley to encompass a wide variety of threats, such as pollution from too many large automobiles, ecological damage, weapons of war, or some as-yet-unknown technology. The woman warns that the risk of future destruction is so great that it should interfere with any pleasure that the father might experience as he walks with his child. The woman does not consider that her extreme warnings are excessive. Her fears for the future are so great that they propel her to warn strangers about the risks the world faces in a future where science and technology are not better controlled.

STYLE

First-Person Narrator

In a short story or novel, the term "narrator" is used to describe the person who tells the story, and a first-person narrator tells the story from his or her limited point of view. The woman is the first-person narrator in "Anxiety," and she is also the protagonist, the central character. She tells the story and interprets it for the reader. The reader learns something about the characters in "Anxiety" and almost nothing about their personal stories. This is because the other characters are filtered through the woman's eyes. The story is limited to the first-person narrator's experiences and observations. The woman lacks the omniscient view of a third-person narrator, in which the author serves as the narrator, offering all views. In some cases, authors use multiple narrators, in which several characters tell their stories. This gives the reader the opportunity to see the characters from multiple perspectives. Since Paley uses only one narrator, readers are limited in their understanding of characters' motivations and must simply interpret their actions. For example, when the father sets his daughter down on the ground so roughly that she rubs her ankle in pain, readers know that the man is angry at the child. This characterization through action is also clearly seen in the depiction of the woman's personality. She peeks out at the people on the street below, watching through the leaves of the plants in the window box, and readers understand that she is a watcher. Paley ultimately reveals to her readers the true nature of her narrator—she is so consumed with worry about the future that she does not participate in the present. She closes the window and sits and worries.

Protest Literature

Protest literature is writing that is designed to generate action. Authors who write protest literature hope to increase social awareness in their readers and thereby bring about change. Protest literature has a long history. Jonathan Swift, Charles Dickens, and Harriet Beecher Stowe used literature as a way to protest the treatment of the disenfranchised citizens of Ireland, England, and the United States, respectively. Paley embraces this tradition and uses her stories as a vehicle to promote her social activism. "Anxiety" reflects the author's concerns about war and the use of technology, which she worries might destroy the world. She refers to the "murder of our children by these men," who present an unnamed and undefined danger. This generalization provides a generic warning about the risk that children face in the future. At the end of the story, Paley labels "these men" as scientists and automakers. Most protest literature is more specific in its warnings, but Paley leaves room for interpretation.

HISTORICAL CONTEXT

Social Activism in the 1980s

Paley's writing was heavily influenced by her desire to create a better world. The early 1980s was a period in which wars were being fought in Afghanistan and in the Falkland Islands. The U.S. embassy in Iran was seized by terrorists, and the U.S. embassy in Lebanon was bombed. This was also a period in which scientists were trying to create more technologically advanced weapons, although there was briefly some hope that such weapons might never need to be used. By the mid-1980s, the Cold War between the Soviet Union and the United States was finally resolving, and it seemed that the long-time tension and threat of war that had existed between the two superpowers since the close of World War II would finally end. Although it appeared that President Ronald Reagan of the United States and General Secretary Mikhail Gorbachev of the U.S.S.R. might together bring peace to the world, Reagan continued to lobby for the creation of a Strategic Defense Initiative, nicknamed Star Wars, which would be capable of intercepting a missile launched by the Soviet Union. Work on the Star Wars program suggested that peace might not last, as so many people hoped.

The effects of industrial pollution led to worldwide acid rain that destroyed trees and plants. In response to worries about the destruction of the environment, a protest group called Greenpeace disrupted nuclear tests planned by the U.S. government. The success of these first protests led Greenpeace to begin working to save endangered animals. The accident at the Three Mile Island nuclear plant, the toxic waste contamination in the Niagra Falls neighborhood of Love Canal, several oil spills throughout the world, and increased activities by terrorist groups, such as the Red Brigades and militant factions of the Palestinian Liberation Organization, are all events that fed Paley's concerns about the state of the world and her worry—voiced in this short story—that children born in the 1980s would not have a world in which to grow if people did not become more involved in protecting the environment.

The Changing Role of Fathers

Although Paley never explicitly refers to a time in which her short story is set, it is reasonable to assume that the setting is the mid- to late 1970s or early 1980s, a time of tremendous social change, especially in the way that families were constructed. This is a period during which women demanded greater equality in the workplace and in the home. Women began to work outside the home in larger numbers, a trend acknowledged by the events in "Anxiety." Paley's female narrator stops a young father walking on the street below her window, tells him that he is "about a generation ahead" in his "attitude and behavior" toward his child. Since Paley's narrator does not know this father, she is basing this comment on

COMPARE & CONTRAST

  • 1980s: By the beginning of the 1980s, the effects of global pollution lead to warnings that the ice at the North and South poles will soon begin to melt. By the middle of this decade a hole in the ozone layer is discovered over Antarctica.

    Today: According to the New York Times, a 2007 United Nations study on global warming confirms that a warming trend is attributable to increased carbon dioxide levels created by humans. The study warns that sea levels could increase between 7 and 23 inches by the end of the twenty-first century due to the melting of the ice caps. Global warming is often considered to pose a significant risk to human life, especially for those who live near coastal areas.

  • 1980s: By the beginning of this decade, there are several terrorist groups well established in Spain (the Basque Fatherland and Liberty group), Italy (the Red Brigades), the Middle East (militant factions of the Palestinian Liberation Organization), and the United Kingdom (the Irish Republican Army). These groups claim responsibility for bombings, sniper attacks, and mass murder, all of which are designed to terrorize the inhabitants of these areas.

    Today: Terrorism remains a problem throughout the world. In addition to the terrorist attacks in New York City and Washington, D.C., on September 11, 2001, there are terrorist attacks in Istanbul, Turkey, in 2003; Madrid, Spain, in 2004; and London, England, in 2005. There are also multiple terrorist attacks in Thailand and Indonesia during the first years of the twenty-first century.

  • 1980s: The assassination or attempted assassination of political, religious, and cultural figures dominates the news during the first half of this decade. Egyptian president Anwar Sadat, Indian Prime Minister Indira Ghandi, and musician John Lennon are assassinated, while U.S. President Ronald Reagan and Pope John Paul II are wounded during assassination attempts.

    Today: The assassination of political figures has continued into the twenty-first century. Assassinated political figures include the prime minister of Serbia in 2003, the president of the Chechen Republic in 2004, a former prime minister of Lebanon in 2005, the mayor of Moscow in 2006, and the former prime minister of India in 2007. Numerous other minor dignitaries are also assassinated.

  • 1980s: An oil crisis at the end of the previous decade causes consumers to buy smaller foreign-made automobiles in the first part of the 1980s. U.S. automakers are unprepared for the increasing popularity of smaller cars and face serious economic problems with the decline in sales of large U.S.-made vehicles.

    Today: The increase in the price of oil in 2008 results in increases in food and transportation costs. The oil crisis also leads to an increased demand for hybrid cars that use less gasoline and a decreased demand for large vehicles, which in turn leads to economic problems for U.S. automakers, who have depended on the sale of large vehicles to make a profit.

  • 1980s: Soviet troops invade Afghanistan, beginning an occupation of that country that will last more than eleven years. The United States provides supplies, including weapons, to help the Afghan guerrilla troops resist the Soviet troops.

    Today: After the terrorist attacks in the United States in September 2001, U.S. troops invade Afghanistan in an effort to capture or kill the group funding and directing terrorist activities against the United States.

what she observes—two fathers who wait for school to end so that they can walk their children home. She has no other information about either the fathers or their children, but clearly her perception is that fathers in the 1980s are becoming more involved in their children's lives than were fathers in previous generations. Traditionally, fathers in earlier generations were the financial providers. Most women assumed responsibility for housekeeping and child care. According to Department of Labor reports, only 17 percent of women with children worked outside the home in 1948, but by 1985, the number of working mothers had climbed to 61 percent. By the end of the 1960s, women began to enter the workforce in larger numbers. Since many of these women were now providing economically for their families, it was expected that fathers would begin to fill the role of nurturer, rather than just provider. While "Anxiety" seems to suggest that this was occurring, some sociological studies challenge this perception. As reported by Ralph LaRossa in his study "Fatherhood and Social Change," a national survey conducted in 1981, just about the time that Paley was writing this story, fathers were spending only about five minutes more per day on average with their children than was reported in a 1975 study. The total time that fathers were spending with their children in 1981 was reported to be about 2.88 hours a week. Mothers reported spending 8.54 hours per week in child care. According to this national study, mothers were spending their time in caretaking, while fathers were spending their time primarily in play with their children. According to LaRossa, grandmothers and professional child care facilities began to fill the gap in child care. LaRossa argues that the perception that fathers were more involved in child care in the early 1980s, which Paley's narrator appears to share, was a folk myth. People wanted fathers to be more involved and simply chose to believe that they were.

Multigenerational Parenting

Paley's narrator is an older woman. The young father whom she accosts from her window refers to her as "that old gray head." In cautioning the father, she is fulfilling the traditional role of the mother, or in this case, the grandmother. The woman narrator even cites the tradition of women watching over the children below as her authority for yelling at him to stop and listen to her. Paley herself grew up in a multigenerational family and knows the importance of having more than two generations under one roof. The role of the grandmother in particular is one of augmenting child care and of passing along the wisdom of age. At the beginning of the twentieth century, new immigrants brought with them a tradition of housing extended families under one roof, just as Paley's family had done. With economic success, however, more families began to live in smaller units, without grandparents in the same household. A housing shortage after World War II led to a temporary increase in multigenerational families living together, but by the beginning of the 1950s, the typical residence once again consisted of parents and children, with only two generations in the same home.

Historian Steven Ruggles and Susan Brower point out that in 1850, 70 percent of the elderly lived with their children, where they were involved in family life and presumably in child care; by 1950, the percentage of elderly living with their children had dropped to 16 percent. Increasing mobility in the latter half of the twentieth century also meant that grandparents often lived a significant distance away from their grandchildren. By the 1960s more parents were divorcing, and by the 1980s, with the divorce rate reaching 50 percent, the family unit was no longer even defined as a father and mother living with their children. Sociologist Vern L. Bengtson suggests that multigenerational relations have once again become important in providing a more stable and nurturing family life for children. In a society with many divorces and the addition of stepparenting and sometimes multiple stepparenting, grandparents provide continuity in children's lives. They also serve as role models, as an economic resource and as a way to relieve the stress on overburdened parents.

Paley's narrator tries to assume the role of grandmotherly advisor and protector when a father is short-tempered and stressed. She cautions the father that he is being too hard on his daughter, and she warns him not to waste precious time with his child by scolding her so harshly. The narrator also worries whether the children are eating healthy foods. All of these concerns are in keeping with the role of the grandmother in a multigenerational family. By the early 1980s, when Paley was writing "Anxiety," the increasing divorce rate, combined with more women entering the workforce, meant that there was a greater need for volunteer help with child care. Paley's pseudo-grandmother suggests that older generations can provide extra help to parents who need guidance and assistance with child care.

CRITICAL OVERVIEW

When Paley died in August 2007, there were many tributes to her work and to the contributions that she had made to the literary world. These tributes did not suddenly appear with her death, as they so often do after a notable person has died. Instead, these tributes most often echoed what was written during her lifetime. When Paley's third collection of short stories, Later the Same Day, was published in 1985, it was reviewed in several publications. In the New York Times Book Review in April 1985, book critic Robert R. Harris states that Paley is "one of the best short-story writers … because of her uncanny ability to juxtapose life's serious and comic sides" in her work. He points out that Paley's stories remain fresh and do not become dated. Harris believes this is because Paley's work "has an honesty and guilelessness" that succeeds with readers because of her "artfully intricate prose style," which continues to surprise the reader and results in "fiction of consequence." In her 1985 review of Later the Same Day, novelist Anne Tyler writes in the New Republic that Paley is "unique, or very nearly unique, in her ability to fit large-scale political concerns both seamlessly and effectively onto very small canvases." Tyler celebrates Paley's talents with language and her ability to create characters whose activism is personal and authentic without displaying the "self-righteousness" that can be offensive to many readers.

In another 1985 review, published in the Washington Post, staff writer David Remnick moves beyond reviewing Later the Same Day and instead focuses on her body of work. Remnick claims that nearly all of Paley's forty-five published short stories are "remarkable for their clarity, their sense of place, their sympathies." Paley, suggests Remnick, is different from other short story writers, who try to be eccentric New York writers. Paley is the "genuine article, unpretentious, funny and wise." She is a writer, says Remnick, who captures the authentic experience of living in the city and of what it means to be a "New York type."

It is worth noting that not all reviewers were as enamored of Paley as Harris, Tyler, and Remnick. In her review for Commentary, Carol Iannone claims that once Paley became involved in protesting the Vietnam War, her stories began to "openly celebrate activism." Iannone does not see Paley's activism as a positive force in her writing. Instead, she asserts, after Paley became focused on antiwar activities, her stories became "skimpy throwaways, poorly thought out and obscure little fragments" that suggest that the writer has her mind focused on other things.

Iannone's analysis of Paley's work has proven to be the minority view. In her Washington Post obituary titled "Acclaimed Short-Story Writer," writer Adam Bernstein refers to Paley as "a master of the short story." In the obituary printed in the Guardian, writer Mark Krupnick states that Paley "was able to create in her fiction a world of voices and an ethnic style that was uniquely her own." Perhaps the most important measure of Paley's legacy as a short story writer is the tribute written by Pauline Watts, dean of Sarah Lawrence College, where Paley taught writing for more than twenty years. In the tribute, posted on the Web site of Sarah Lawrence College, Watts refers to Paley as an "iconoclastic writer" and notes the important role that Paley played in establishing the writing program at Sarah Lawrence. Paley, says Watts, thought that teaching writing was "a way to introduce young people to the difficult, life-long task of telling the truth." Her ability to influence young writers was one reason that her classes at Sarah Lawrence were so popular and suggests that her legacy as a writer is as much about teaching as it is about writing.

CRITICISM

Sheri Metzger Karmiol

Karmiol has a doctorate in English Renaissance literature and teaches literature and drama at the University of New Mexico. She is also a professional writer and the author of several reference texts on poetry and drama. In this essay, Karmiol discusses the depiction of the Jewish mother figure in "Anxiety."

In Grace Paley's three collections of short stories, she has frequently depicted the life of one central character, Faith Darwin, as she ages throughout the series of stories. Although Paley never mentions the name of the woman narrator in "Anxiety," it is likely that the narrator is Faith since, in a subsequent story in Later the Same Day, titled "The Story Hearer," Faith refers to an encounter with the young fathers earlier in the day. Faith is a mother, and more importantly, she is a Jewish mother, whom Paley uses as a vehicle to explore the people and places of her own life. The stereotype of the Jewish mother as a manipulating, guilt-inducing, nagging woman has been so prevalent in twentieth-century literature, film, and culture that she is a readily identifiable stock character for audiences of Jews and non-Jews alike. By the 1950s, when Paley began publishing the first of her short stories, the Jewish mother had become a caricature of motherhood. Paley uses her story "Anxiety" as a way to present a more positive depiction of motherhood that counters the negative stereotypes that the term "Jewish mother" presents. Paley does not simply refute this stereotype; she recasts her woman narrator in the image of the strong immigrant woman who first leaned out the windows fifty years earlier.

WHAT DO I READ NEXT?

  • The Little Disturbances of Man: Stories of Women and Men at Love (1959) was Paley's first collection of short stories. These first stories established Paley as a regional author whose characters were the people of her native New York City.
  • Paley's second collection of short stories, Enormous Changes at the Last Minute, was published in 1974. This collection of stories reflects the author's activism and her concern about social issues. Several of these stories continue the story of Faith Darwin, who appeared in Paley's first collection of stories.
  • Paley's Long Walks and Intimate Talks (1991) is a collection of short stories and poetry. Paley's character, Faith, is also present in the prose selections that appear in this book. The poems are more political than the stories, and both stories and poems are complemented by the paintings of artist Vera Williams.
  • Just as I Thought, published in 1998, is a collection of Paley's essays, columns, and brief newsletter reflections. The pieces in this collection are autobiographical, so they provide information about Paley's life as well.
  • A Cynthia Ozick Reader (1996), edited by Elaine M. Kauver, is a collection of Ozick's stories and poetry. Ozick is often compared to Paley. Like Paley, Ozick's stories focus on the lives of women, especially Jewish women.
  • The Woman Who Lost Her Names: Selected Writings by American Jewish Women (1980), edited by Julia Wolf Mazow, is a collection of short stories that depict Jewish women in roles that move away from the stereotypes that portray Jewish women as either the Jewish American princess or the Jewish mother.
  • The Oxford Book of American Short Stories (1992), edited by Joyce Carol Oats, is a collection of stories by some of the best-known American writers. What makes this collection interesting is that the editor has chosen to include a selection of stories that are less familiar to readers.

For Paley, a Jewish mother is a positive image of motherhood. Paley's mother figure is not the comic stereotype that became a standard of Jewish comedians, nor is she the overpowering emasculator depicted by Jewish male writers like Philip Roth, who in his novel Portnoy's Complaint creates a Jewish mother in control of every aspect of her son's behavior. In an interview with Ellen Rothman for Mass Humanities newsletter, Joyce Atler, the Samuel Lane Professor of American Jewish History at Brandeis University, says that Paley has given readers a very different portrait of the Jewish mother. Atler claims that for Paley, "mothering was a central artistic concern" in her work that provided "innovative, positive models of Jewish matriarchs." Atler's studies of Jewish mothers has revealed a tradition of mothers "who raised their children with moderate, flexible methods, passing on their own morals and values." The need to pass on wisdom and moral values is what motivates the actions of Paley's narrator, who feels compelled to offer advice and even some warnings to the parents who pass outside her window. When Paley's woman narrator sees a young father obviously annoyed with his daughter, she feels compelled to intervene. Her authority to do so, she tells readers, is the long tradition of Jewish mothers, women like the narrator, who leaned out of their windows, often as high up as the fifth floor, and yelled instructions and warnings to their children playing on the sidewalk or in the street outside.

Paley's woman narrator is cast in the tradition of these women whose strength and guidance helped their families survive and thrive after they arrived in the United States. In an essay written in the late 1970s called "Other Mothers," Paley begins with a familiar image from life in the city's tenement buildings: "The mother is at the open window." She is an observer of life who calls her children home and who, according to Paley, keeps her husband "from slipping" back down the rung of the ladder that he must climb if he will find success in this new country. The mother in Paley's short essay is cast in the image of that immigrant mother, the model for Paley's narrator in "Anxiety," who leans out the window and watches the world unfold beneath her. Atler claims that the stereotypes associated with the Jewish mother reflect the tension that immigrants felt when they first arrived in the United States at the beginning of the twentieth century. The anxieties that were created in leaving their homes for a new country, says Atler, "were often written onto the Jewish mother," whose dual personality was both "nurturant and encouraging" and "materialistic and manipulative." The Jewish mother was not given the opportunity to escape from her immigrant status, as her sons were. Instead, the Jewish mother was turned into a caricature—a mother, according to Martha Ravits, who must die before her son can become a man. In her essay "The Jewish Mother: Comedy and Controversy in American Popular Culture," Ravits traces the social, historical, and literary traditions that took Jewish women from a representation of a strong, independent immigrant woman, who capably helped her husband and children succeed, to a role of derision and an object of ridicule for Jewish comics. According to Ravits, the image of Jewish mothers evolved into a depiction of women who were unable to "observe the boundaries between proper parental concern and overprotection." The Jewish mother in film, literature, and popular culture was defined by a voice that "overflows with unsealed emotion and verbal excess." The Jewish mother loves too much and criticizes too much, and it is her son who bears the brunt of all this too-motherly love. By making the parents outside the narrator's window fathers, rather than mothers, Paley is able to counter this image of negative motherhood consuming and devouring the male progeny of Jewish mothers.

According to Ravits, there was a well-established tradition of making fun of mothers already in place before the Jewish mother became such an important part of American culture. The stereotype of the Jewish mother is a woman who questions male authority, voices too many concerns, and does so too loudly and too aggressively. Fortunately, with the passage of time, that depiction of the Jewish mother has become balanced with a more positive image, in large part because of writers such as Paley, whose works create a more positive image of Jewish mothers. Ravits claims that by the 1990s, the Jewish mother had become transformed into just another mother. Ravits credits this to a more secure place in American society for Jewish Americans, in which their ethnicity is less of a factor impacting their place in society. Ravits notes that during the cultural transition, where Jews were becoming assimilated into American life, "the stereotype of the Jewish mother was constructed to signify and mock Jews' concerns about the process of Americanization." Having the mother represent the old, pre-immigrant lifestyle allowed her children the opportunity to claim that they were more truly American than their parents. Ravits also suggests that the Jewish mother helped to diffuse anti-Semitism since both Jews and non-Jews could laugh together at the Jewish mother, who in truth was not much different from the Italian mother or the Irish mother.

For Paley, mothers, especially her own, have an important function in her work. In her essay "Other Mothers," Paley begins with the mother at the window, but she quickly moves to remembrances of mothers from her past, including her own mother. These were strong, wise women, women Paley remembers from fifty years ago. The past, though, continues to be a part of who she is: the "daughter of mothers." The connection to her mother is never far from Paley's writing. In "The Outsider Within: Women in Contemporary Jewish-American Fiction," Victoria Aarons says that it is "the figure of the mother [who] provides a deep connection to the past." It is the mother whose knowledge of the past is used to filter knowledge of the future. In Paley's world, mothers sit on the stoop outside their tenement buildings or lean out of their windows, and they talk to their neighbors and to those who pass by on the street. It is the mother, according to Aarons, who "because of her garrulity and penchant for participating actively in the lives of her neighbors," becomes a source of information for her family. This is the tradition of mother as a source of caution and information that Paley depicts in her women narrator. This is a woman who has something to say about the world she inhabits. Paley imbues her woman narrator with knowledge and a social and ecological awareness that needs to be voiced. From her window above the street, she can see farther, and as Paley's narrator makes clear, she can also see into the future clearly enough to warn those who pass below of the dangers that await them.

There is no hesitation for the woman narrator in "Anxiety." She is quick to stop the fathers, to yell, "Stop! Stop!" She knows that she is needed to offer advice and to stop this father, who seems not to recognize his daughter as one of the "lovely examples of what may well be the last generation of humankind." This narrator knows that what she has to tell the father is important. In her essay "To Aggravate the Conscience: Grace Paley's Loud Voice," Rose Kamel asserts that Paley's women narrators exhilarate readers "with a jaunty confidence that they have something vital to say" and that they have an "authority to which we cannot help but pay close attention." Certainly it is obvious that the young father in "Anxiety" is attentive to the woman's warnings, since he turns "a serious face" to the woman. Kamel also claims that Paley's narrators have "a creative sympathy for all children." This sympathy invigorates these narrators and makes them brave enough to accost strangers, especially when the goal is to protect a child. The narrator in "Anxiety" does not intrude on the father and child to be nosy or argumentative. She does so to offer wisdom and knowledge that she hopes will help protect the child. Although it appears that the narrator yells "Stop! Stop!" because she observes the father being too rough with his child, the woman yells at the father because she has a more serious warning to pass on. In a short essay titled "One Day I Made up a Story," first published in the War Resisters Calendar in 1985, Paley writes about the creation of the story "Anxiety." She explains that "I imagined a wild old woman leaning on her elbows at her open window, next door to the schoolyard, making a speech to the street." The old woman did not do this just the one time, as readers witness in reading "Anxiety"; she does it repeatedly. Paley states that after the woman closed the window, she played the piano for a while, but then "she opened the window and shouted again: Stop! Listen!" The old woman functions as a sort of town crier, warning those who come into her line of vision of the danger that lies in their future.

Paley uses her imagination and her memories of Jewish mothers from the tenements to create characters and situations that incorporate the traditions of her youth, while taking the text somewhere new and different. The street is dangerous, but so is the world. It is not just the busy traffic, with those huge cars that pollute the environment, that concerns Paley's narrator in "Anxiety." The world presents a danger that can best be viewed from the windows above, just as it always was in the past. Ravits claims that the Jewish mother, who emerged from the old stereotypes, remains "a cautionary figure" who still warns about the dangers that her listeners face. Paley's woman narrator is not concerned that she will be thought pushy or obnoxious, and she is unafraid of the Jewish mother stereotype that might silence her. Instead, this woman sees herself as fulfilling an important role. This Jewish mother is a woman of strength and endurance whose responsibility to protect the future is always taken seriously.

Source: Sheri Metzger Karmiol, Critical Essay on "Anxiety," in Short Stories for Students, Gale, Cengage Learning, 2009.

Kasia Boddy

In the following interview with Boddy, Paley shares her perspectives on being a Jewish woman writer.

… [KASIA BODDY]: This morning you said that you had been looking forward to a disagreement with Cynthia Ozick (who pulled out of the conference).

[Grace Paley]: We have political disagreements. She's a very strong Zionist. That's what she is, so, I'm not, and I never was. I wish Israel well. I have very good feelings towards it. I'm very upset now about [Ariel] Sharon and the way he's doing things—it really bothers me a lot: I think it's not only bad but stupid. Those would be our basic disagreements. I make a joke of it. She probably doesn't like that.

KB: Has she written anything about recent events?

GP: Well, I haven't read it. I haven't read a lot of stuff. I read a lot but I also miss a lot. I don't live in New York and a lot of things are happening that I miss. In a way it's good for me, but in a way….

KB: Do you regret not living there?

GP: I do somewhat. I'm so used to being in on everything and so here I am not in on everything. But I'm in on enough, I guess, for my age, so it's okay! Shouldn't complain.

KB: You were talking about Isaac Babel this morning, and I recently read Antonia Pirizhkovova's memoir of Isaac Babel, At His Side, and your foreword.

GP: Oh you did?

KB: It's fascinating. And Babel's own writing is being reprinted.

GP: But the new translations are not good.

KB: Can I ask a little about what you say in the foreword to the memoir?

GP: Yes.

KB: You say of Babel that ‘He didn't like literary talk. He didn't want to discuss his own work.’

GP: That's what he said: that's what she said he said!

KB: You've given, very generously, many interviews over the years. How do you feel about literary talk, about discussing your own work?

GP: I don't mind. I'm very much against mystification of anything. If people don't really know what's going on, I want them to know.

KB: How do you demystify the writing?

GP: I would be always glad to tell a class which little piece seems to me to have happened or that I heard and which piece is totally invented. People like to know that and I don't see why I shouldn't tell them.

KB: Do you get anything out of talking about your work, or is it always something you do for their sake?

GP: Sometimes talking about your work is very helpful, at a certain point in your life. I really don't need to talk about my work anymore. But sometimes you learn something—people ask you certain questions and you say, ‘Oh, so that's what they think I'm doing’. Maybe those questions didn't help me write better but they made me think better about what I thought I was doing.

KB: In relation to that, I want to ask you about something you mentioned today, and talk about quite a lot elsewhere—the importance of generations and generational differences. I really like your poem ‘People in My Family’—how different are the people born around 1914 from those born in 1905. How much do you think who you are, and what you believe, is determined by when, and where, you were born?

GP: That poem was really describing my sister and brother who are fourteen and sixteen years older than me and who were really born into the Depression. They have a slightly anxious feeling, which I never had. I was born into the War and so I was in a state of fury and so forth and so on. I became a pacifist, which they never did.

KB: Into fury and not fear?

GP: Well, I was in America and war was here; Europe was where people were suffering. I was married to a boy. I was very young then, and he went overseas. Before he went to the Pacific—both my husbands went to the Pacific—I lived on army camps. It was very interesting.

KB: Do you think that your writing is also shaped by your generation? By that moment?

GP: It must be. How could it not be?

KB: Your writing has had a big influence on several generations of writers (and critics) since you first published The Little Disturbances of Man in 1959. In the Sixties you were read as a metafictionist, in the Seventies as a feminist, now, within discussions of multiculturalism, perhaps the emphasis again is on Jewishness. Each generation picks out a different strand.

GP: What's interesting to me is that young people are interested in it, in such an old book! That's pretty thrilling! I'm sure some of them read me differently. The Women's Movement bloomed in the late Sixties and Seventies, but the women who made it were writing before that—not just me, Tillie Olsen,Muriel Rukeyser.

KB: Now though no one wants to talk about women's voices. They want to talk (here anyway) about Jewishness, about ethnicity.

GP: I'll tell you what happened at the Princeton conference a week ago. Similar discussions were being held. Morris Dickstein gave a talk that was about Jewish writers and power, and the power of the State. His point was that Bellow and Roth and even Malamud had held back from dealing with the power of the State and instead were dealing almost entirely with local affairs. But it was only about men. Suddenly a woman at the back got up and she asked what about Jewish women writers, and she mentioned my name and she mentioned two or three other names. And then Alice Hofstrucker got up very furious, and she said what about the poets, what about Adrienne Rich, and so on. He looked so appalled that I felt like comforting him later and saying there's still time for you, you're a young man, write your next chapter and put the ladies in! That's what Abigail Adams said when her husband was writing the Declaration of Independence; she said, ‘Remember the ladies’. It is hard to hear about these guys all the time as if they are the only people writing. It doesn't bother me so much because I'm really past all that stuff, but it bothers me for young women that they're going to have to repeat the struggle.

KB: There wasn't much today about young Jewish writers, the current generation.

GP: That's absolutely right. At Princeton there were some younger writers but they were in such a state. They were the children of survivors and they were in rage that it wasn't paid enough attention to. It was quite … yet I understood how they felt.

KB: Have you noticed your own influence on young writers?

GP: I don't think about it.

KB: But do people tell you about it?

GP: Yes, people tell me that ‘I couldn't have written this or that without you….’ It's nice, but there's a danger in leaning on that stuff and let[ting] it enter you. Too much work still to do.

KB: Gish Jen is one writer who's talked about your work, and who I've read you like.

GP: Yes, I like her. She was just at Dartmouth. She's a good friend of mine.

KB: I really like her. I teach her books.

GP: You do? I must tell her. She'll be so happy. She's such a doll.

KB: About four years ago she wrote an essay about being a judge for the PEN/Faulkner award in which she complained that multiculturalism had become both a ‘pigeon-hole and an albatross’.

GP: She would say that she doesn't want to write as a Chinese woman. On the other hand, most of her experience is as a Chinese woman. Her father is Chinese, her mother is Chinese, her brothers are Chinese—they're all of course married to white Americans, including her! But still, if you asked Cynthia Ozick if she wanted to be considered as a Jewish writer she would say no; she would say I am a writer, and she would be right. I say, yes I'm Jewish so therefore I'm a Jewish writer. But writing in Jewish is a whole different scene which I tried to make clear this morning.

KB: What does Gish Jen write in?

GP: She writes a little bit in Chinese I think. She read a story that could have been in sheer dialect: that could have been her mother.

KB: Oh yes, ‘Who's Irish?’

GP: Yes. It's very funny.

KB: Very funny story. So you don't think she had a genuine complaint about the literary world?

GP: She doesn't want to be pigeon-holed; I don't want to be pigeon-holed. Everybody wants to be in the mainstream. They don't realize that when you're not in the mainstream, it's glorious; you're free. The mainstream is just a sluggish river; it's got so many people in it already. Better to be in some river, stumbling over the rocks. It's better. That's how I feel.

KB: Is there as definite a sense of the mainstream now as when you started writing?

GP: That's funny. What they're talking about is exactly what was going on then. Roth's first book and my first book were published at the same moment practically and were reviewed together in a lot of magazines, and were equally praised. Then we were told to write novels. And he wrote novels. And I tried for two years to write a novel but I failed. So. It was so terrible, so pedestrian. I can't tell you.

KB: In your foreword to the Babel memoir you speak of his ‘small production’ and say that ‘for some reason I feel this must be answered’.

GP: And then I pointed out that he really did lots of other writing, he wrote a screenplay, lots of shift work.

KB: Did you feel you wanted defend him partly because you face the same issue: that people are always urging you to write more, write longer?

GP: No, I didn't defend him for that reason. I defended him for his own reasons! One, I thought he had done great literary work and two, he had to go off for the party and visit farms and do agricultural reports and stuff like that.

KB: Although you haven't had to do that, you've also done a lot of non-literary work.

GP: Yeah.

KB: In Amy Bloom's latest book, A Blind Man Can See How Much I Love You, she has a story (‘Rowing to Eden’) in which a character promises to help her friend get a girlfriend with ‘Grace Paley's soul in Jennifer Lopez's body’.

GP: I saw it. That was so funny. The soul of me. That was so touching.

KB: What do you think she means?

GP: I don't know. I don't know if she meant something bad or good, but I'm sort of touched by it—by my having a soul at all!

KB: Can I ask a little about your poetry?

GP: Oh yes, do!

KB: Partly about the relationship between writing poems and stories. In ‘Two Ears, Three Lucks’ in The Collected Stories you talk of suffering ‘the storyteller's pain’ that led you away from poetry. Yet you continued, you continue to write poetry.

GP: I just find myself writing poems and feeling good about it.

KB: What makes you want to write a poem rather than a story (and vice versa)?

GP: Sometimes I don't know. Sometimes I begin by writing a couple of sentences that might go one way or the other. But I think that I'm just in the mode for writing poems right now. Actually my intention when I get home is to get to work on two stories that I have in mind. I can't wait; I'm very eager to do it. I don't have enough poems for another book but I will probably by the end of next summer.

KB: You have ‘A Poem About Storytelling’ and many stories with poems in them, so in a way maybe they're not so separate after all.

GP: Well, I think that short stories are very close to poetry. If you write poetry and you write novels you're doing two different things. If you write short stories and you write poetry then you're doing things not so far apart from each other.

KB: Edgar Allan Poe said that a short story had all the beauty of a poem but some of the truth of prose.

GP: I didn't know that! That's nice!

KB: Is there less truth in poetry?

GP: No, I don't think so. What he really means is events….

KB: Facts.

GP: Yes.

KB: The word you use, again about Babel's language, is density.

GP: A short story, like a poem, is something that you almost feel you could take in your hand and lift up to the air and the light—and have it all in one hand. With a novel it's like you're scrambling around and picking this up and that up and you have all this stuff in your arms.

KB: You said of Babel's technique that he would start with longer, looser sentences and then condense and condense until he achieved the right density of language. Is that your method too?

GP: Not necessarily. Sometimes I increase and increase! It depends. But I do think that I'm a pretty good cutter of the unnecessary.

KB: So you go through lots of drafts?

GP: Oh yeah. Let me show you. [she produces a folder full of typewritten and pen-amended pages and starts leafing through them] … Here's something I can't even get back to because it's long and it's complex and I haven't [been] able to work on all this. Partly I can't because there's not enough pressure on me to do it.

KB: Do you rotate between different manuscripts?

GP: I suppose I do, but once I start really working on something I stay with it.

KB: As a definition of the short story Leonard Michaels once quoted a line from Kafka, ‘A bird went flying in search of a cage.’

GP: That's really nice. And a definition of a long story might be ‘A man went looking for a prison cell.’

KB: So at least the short story has some flight! Is ending a story like closing the door of the cage?

GP: Sometimes I like to tie things up; sometimes I like to open it up. I don't have an opinion on what's the best way to do it. I don't like writers who cut their characters off when if they'd let them live another half day it would have all been different. It's manipulative and I don't like it.

KB: Do you think your stories ever operate as Kafka-like parables or lessons? The word ‘lesson’ does come up sometimes; one character teaching another something about life.

GP: Right. The story I'll read tomorrow is ‘My Father Teaches Me to Grow Old’.

KB: I read that in a magazine a long time ago.

GP: No, no, you must have read about two pages. It's now eleven.

KB: The Portable Lower East Side, wasn't it?

GP: Yeah, right. That's where it came from. I had it lying there until what? a half year ago. Now I finished it. I changed a lot of it, not an enormous amount, but I did a lot of cutting.

KB: I liked it a lot the old way!

GP: Well, I changed the title and added another nine pages.

KB: I look forward to hearing it. Other stories seem more arguments than lessons.

GP: Right. I do a lot of that, a lot of arguing. I write against things sometimes. Not in opposition so much, but leaning on the facts.

KB: Is writing in arguments a way of writing in Jewish?

GP: Very often, very often.

Source: Kasia Boddy, "An Interview with Grace Paley, 26 October 2001," in European Journal of American Culture, Vol. 21, No. 1, January 2002, pp. 26-33.

Vivian Gornick

In the following review, Gornick expresses admiration for Paley's voice in her stories, noting that this voice has become an important influence on the contemporary American short story.

I remember the first time I laid eyes on a Paley sentence. The year was 1960, the place a Berkeley bookstore, and I a depressed graduate student, leafing restlessly. I picked up a book of stories by a writer I'd never heard of and read: "I was popular in certain circles, says Aunt Rose. I wasn't no thinner then, only more stationary in the flesh. In time to come, Lillie, don't be surprised—change is a fact of God. From this no one is excused. Only a person like your mama stands on one foot, she don't notice how big her behind is getting and sings in the canary's ear for thirty years." The next time I looked up it was dark outside, the store was closing, and I had completed four stories, among them the incomparable "An Interest in Life" and "The Pale Pink Roast." I saw that the restlessness in me had abated. I felt warm and solid. More than warm: safe. I was feeling safe. Glad to be alive again.

There have been three story collections in 35 years. They have made Paley internationally famous. All over the world, in languages you never heard of, she is read as a master storyteller in the great tradition: people love life more because of her writing. In her own country Paley is beloved as well, but it's complicated. Familiarity is a corrective. Limitations are noted as well as virtues. The euphoria is harder-earned. For many American readers, the third collection is weaker by far than the first. Scope, vision and delivery in a Paley story seem never to vary or to advance; the wisdom does not increase; the cheerful irony grows wearisome, begins to seem folksy. Oh Grace! the critically-minded reader berates a page of Paley prose, as though it were a relative. You've done this before. And besides, this, what you have written here, is not a story at all, this is a mere fragment, a little song and dance you have performed times without number.

Then suddenly, right there, in the middle of this same page refusing to get on with it, is a Paley sentence that arrests the eye and amazes the heart. The impatient reader quiets down, becomes calm, even wordless. She stares into the sentence. She feels its power. Everything Paley knows went into the making of that sentence. The way the sentence was made is what she knows: just as the right image is what the poet knows. The reader is reminded then of why—even though the stories don't "develop" and the collections don't get stronger—Paley goes on being read in languages you never heard of.

No matter how old Paley characters get they remain susceptible to the promise that someone or something is about to round the corner and make them feel again the crazy, wild, sexy excitement of life. Ordinary time in a Paley story passes like a dream, embracing the vividness of remembered feeling. Age, loss of appetite, growing children, economic despair, all mount up: "normalcy" surrounds the never-forgotten man, moment, Sunday morning when ah! one felt intensely.

Strictly speaking, women and men in Paley stories do not fall in love with each other, they fall in love with the desire to feel alive. They are, for each other, projections and provocations. Sooner or later, of course (mostly sooner), from such alliances human difficulty is bound to emerge, and when it does (more often than not), the sensation of love evaporates. The response to the evaporation is what interests Paley. She sees that people are either made melancholy by loss of love, or agitated by it. When agitated they generally take a hike, when melancholy they seem to get paralyzed. Historically speaking, it is the man who becomes agitated and the woman who becomes melancholy. In short, although each is trapped in behavior neither can resist and both will regret, men fly the coop and women stand bolted to the kitchen floor.

This sense of things is Paley's wisdom. The instrumental nature of sexual relations is mother's milk to the Paley narrator. She knows it so well it puts her beyond sentiment or anger, sends her into a Zen trance. From that trance has come writer's gold: the single insight made penetrating in those extraordinary sentences. Sentences brimming with the consequence of desire once tasted, now lost, and endlessly paid for.

Two examples will do: Faith Darwin—of "Faith in the Afternoon"—is swimming in misery over the defection of her husband Ricardo. When her mother tells her that Anita Franklin, a high-school classmate, has been left by her husband, Faith loses it:

…At this very moment, the thumb of Ricardo's hovering shadow jabbed her in her left eye, revealing for all the world the shallowness of her water table. Rice could have been planted at that instant on the terraces of her flesh and sprouted in strength and beauty in the floods that overwhelmed her from that moment through all the afternoon. For herself and Anita Franklin, Faith bowed her head and wept.

Now, the obverse. In "Wants," the Paley narrator runs into her ex-husband and has an exchange with him that reminds her

He had had a habit throughout the twenty-seven years of making a narrow remark which, like a plumber's snake, could work its ways through the ear down the throat, halfway to my heart. He would then disappear, leaving me choking with equipment.

These sentences are born of a concentration in the writer that runs so deep, is turned so far inward, it achieves the lucidity of the poet. The material is transformed in the sound of the sentence: the sound of the sentence becomes the material; the material is at one with the voice that is speaking. What Paley knows—that women and men remain longing, passive creatures most of their lives, always acted upon, rarely acting—is now inextricable from the way her sentences "talk" to us. She is famous for coming down against the fiction of plot and character because "everyone, real or invented, deserves the open destiny of life," but her women and her men, so far from having an open destiny, seem hopelessly mired in their unknowing middle-aged selves. It is the narrating Paley voice that is the open destiny. That voice is an unblinking stare, it is modern art, it fills the canvas. Its sentences are the equivalent of color in a Rothko painting. In Rothko, color is the painting, in Paley, voice is the story.

Like that of her friend Donald Barthelme, Grace Paley's voice has become an influential sound in contemporary American literature because it reminds us that although the story can no longer be told as it once was, it still needs to go on being told. The idiosyncratic intelligence hanging out in space is now the story: and indeed it is story enough. I felt safe in its presence in a Berkeley bookstore thirty years ago, it makes me feel safe today. As long as this voice is coming off the page I need not fear the loss of the narrative impulse. I need not, as Frank O'Hara says, regret life.

Source: Vivian Gornick, Review of The Collected Stories by Grace Paley, in Women's Review of Books, Vol. 11, No. 10/11, July 1994, pp. 29-30.

Wendy Smith

In the following essay, Smith discusses the political and social activism of Paley's short story characters.

Grace Paley has been a respected name in American letters for years. Her new book of short stories, Later the Same Day, confirms her as an utterly original American writer whose work combines personal, political and philosophical themes in a style quite unlike anyone else's.

Paley's characters, women and men who have committed themselves to trying to alleviate some of the world's myriad woes, usually appear in print as activists at demonstrations, marching with upraised fists. She has given them children, friends, lovers, aging parents, financial worries, shopping lists—in short, a private life to go with their public activities. Paley's work is political without being didactic, personal without being isolated from the real world.

This striking individuality accounts for the profound impact of Paley's writing, despite what is to her admirers a distressingly small body of work. Her first book, The Little Disturbances of Man, appeared in 1959; readers had to wait 15 years for the next one, Enormous Changes at the Last Minute, and just over a decade for Later the Same Day. "I do a lot of other things as well," explains the author. "I began to teach in the mid-'60s, and at the same time there was the Vietnam War, which really took up a lot of my time, especially since I had a boy growing towards draft age. And I'm just very distractable. My father used to say, ‘You'll never be a writer, because you don't have any sitzfleisch,’ which means sitting-down meat."

Her father's comment is hard to believe at the moment, as Paley sits tranquilly in a wooden rocking chair in the sunny living room of her Greenwich Village apartment. A small, plump woman in her early 60s, with short, white hair framing a round face, she resembles everyone's image of the ideal grandmother (so long as that image includes slacks, untucked shirttails and sneakers). As she does every Friday, she is simmering soup on the stove in her large, comfortable kitchen; she regrets that it's not ready yet, as she thinks it would be good for her interviewer's cold. She has to content herself with offering orange juice, vitamin C and antihistamines. Many of Paley's stories express her deep love of children; meeting her, one realizes almost immediately that her nurturing instincts extend beyond her own family to include friends and even a brand-new acquaintance. It's this pleasure in caring for others that makes her activism seem so undogmatic and natural, a logical extension of the kind of work women have always done. It's more complex than that, of course—lifelong political commitments like Paley's don't arise out of anything so simple as a strong maternal instinct—but it helps to explain the matter-of-fact way in which the author and her characters approach political activity as the only possible response to the world's perilous state.

The direction of Paley's work is guided by similarly concrete considerations. One of the reasons she switched from poetry, her first love, to short stories was that she couldn't satisfactorily connect her verse with real life. "I'd been writing poetry until about 1956," she remembers, "and then I just sort of made up my mind that I had to write stories. I loved the whole tradition of poetry, but I couldn't figure out a way to use my own Bronx English tongue in poems. I can now, better, but those early poems were all very literary; they picked up after whatever poet I was reading. They used what I think of as only one ear: you have two ears, one is for the sound of literature and the other is for your neighborhood, for your mother and father's house."

Her parents had a strong influence on Paley, imbuing her with a sense of radical tradition. "I'm always interested in generational things," she says. "I'm interested in history, I'm interested in change, I'm interested in the future; so therefore I'm interested in the past. As the youngest child by a great deal, I grew up among many adults talking about their lives. My parents were Russian immigrants. They'd been exiled to Siberia by the Czar when they were about 20, but when he had a son, he pardoned everyone under the age of 21, so they got out and came here right away. They didn't stay radical; they began to live the life of the immigrant—extremely patriotic, very hardworking—but they talked a lot about that period of their lives; they really made me feel it and see it, so there is that tradition. All of them were like that; my father's brothers and sister all belonged to different leftist political parties. My grandmother used to describe how they fought every night at the supper table and how hard it was on her!"

As Paley grew older, there were family tensions. "My parents didn't like the direction I was going politically," she recalls. "Although my father, who mistrusted a lot of my politics, came to agree with me about the Vietnam War; he was bitterly opposed to it." Her difficulties with her mother were more personal. "One of the stories in the new book, ‘Lavinia,’ was told to me by an old black woman, but it's also in a way my story," she says. "My mother, who couldn't do what she wanted because she had to help my father all the time, had great hopes for me. She was just disgusted, because all I wanted to do at a certain point was marry and have kids. I looked like a bust to my family, just like the girl Lavinia who I'm convinced will turn out very well.

"There's no question," she continues, "that children are distracting and that for some of the things women want to do, their sense is right: they shouldn't have children. And they shouldn't feel left out, because the children of the world are their children too. I just feel lucky that I didn't grow up in a generation where it was stylish not to. I only had two—I wish I'd had more."

The experience of her own children confirmed Paley's belief that each generation is shaped by the specific historical events of its time. "I often think of those kids in the Brinks case," she says, referring to the surviving fragments of the SDS, who were involved in the murder of a bank guard during an attempted robbery in the early 1980s, after they had spent years underground. "If they had been born four years later, five years earlier…. It really was that particular moment: they were called. In one of the new stories ["Friends"], I talk about that whole beloved generation of our children who were really wrecked. I mean, I lived through the Second World War, and I only knew one person in my generation who died. My children, who are in their early 30s, I can't tell you the number of people they know who have died or gone mad. They're a wonderful generation, though: thoughtful, idealistic, self-giving and honorable. They really gave.

"The idea that mothers and fathers raise their kids is ridiculous," Paley thinks. "You do a little bit—if you're rich, you raise a rich kid, okay—but the outside world is always there, waiting to declare war, to sell drugs, to invade another country, to raise the rents so you can't afford to live someplace—to really color your life. One of the nice things that happens when you have kids," Paley goes on, "is that you really get involved in the neighborhood institutions. If you don't become a local communitarian worker then, I don't know when you do. For instance, when my kids were very little, the city was trying to push a road through Washington Square Park to serve the real estate interests. We fought that and we won; in fact, having won, my friends and I had a kind of optimism for the next 20 years that we might win something else by luck." She laughs, as amused by her chronic optimism as she is convinced of its necessity. "It took a lot of worry, about the kids and buses going through the park at a terrific rate, to bring us together. You can call it politics or not; it becomes a common concern, and it can't be yours alone any more."

Paley believes such common concerns will shape future political activism. "One of the things that really runs through all the stories, because they're about groups of women, is the sense that what we need now is to bond; we need to say ‘we’ every now and then instead of ‘I’ every five minutes," she comments. "We've gone through this period of individualism and have sung that song, but it may not be the important song to sing in the times ahead. The Greenham women [antinuclear demonstrators who have set up a permanent camp outside the principal British missile base] are very powerful and interesting. When I went there the first time, I saw six women sitting on wet bales of hay wearing plastic raincoats and looking miserable. It was late November, and they said that on December 12 they were having this giant demonstration. I thought, ‘Oh these poor women. Do they really believe this?’ Well, three weeks later, on December 12, they had 30,000 women there. You really have to keep at it," she concludes. "It's vast; it's so huge you can hardly think about it. The power against us is so great and so foolish."

Yet Paley has never despaired—she notes in the story "Ruthy and Edie" that her characters are "ideologically, spiritually and on puritanical principle" against that particular emotion. "People accomplish things," she asserts. "You can't give up. And you can't retreat into personal, personal, personal life, because personal, personal, personal life is hard: to live in it without any common feelings for others around you is very disheartening, I would think. Some people just fool themselves, decide they have to make a lot of money and then go out and do it, but I can't feel like that." Her voice is low and passionate. "I think these are very rough times. I'm really sorry for people growing up right now, because they have some cockeyed idea that they can get by with their eyes closed; the cane they're tapping is money, and that won't take them in the right direction."

Despite the enormous amount of time and energy political matters absorb in Paley's life, they remain in the background of her fiction. "I feel I haven't written about certain things yet that I probably will at some point," she says. "I've written about the personal lives of these people; I haven't really seen them in political action, and I don't know if I need to especially, for what I'm trying to do. There has to be a way of writing about it that's right and interesting, but I haven't figured it out. I've mainly been interested in this personal political life. But I refer peripherally to things: in ‘Living’ in Enormous Changes, where [the protagonist] is bleeding to death, she remembers praying for peace on Eighth Street with her friend; in ‘Zagrowsky Tells’ in Later the Same Day, he's furious because they picketed his drugstore. That's the way a lot of politics gets in, as part of ordinary people's lives, and that's really the way I want to show it, it seems to me now. What I want is for these political people to really be seen."

The people who aren't seen much in Later the Same Day are men: Jack, the live-in lover of Faith (Paley's alter ego among her work's recurring characters), is a fairly well developed presence, but the book's focus is strongly female. "It wasn't that I didn't want to talk about men," Paley explains, "but there is so much female life that has so little to do with men and is so not-talked-about. Even though Faith tells Susan [in "Friends"], 'You still have him-itis, the dread disease of females, and they all have a little bit of that in them; much of their lives really does not, especially as they get older. I haven't even begun to write about really older women; I've only gotten them into their late 40s and early 50s."

Is Paley bringing her characters along to her own current stage of life? "I'm very pressed right now for time to write; I just feel peevish about it," she says. "But I've always felt that all these things have strong pulls: the politics takes from the writing, the children take from the politics, and the writing took from the children, you know. Someone once said, 'How did you manage to do all this with the kids around? and I made a joke; I said, ‘Neglect!’ But the truth is, all those things pull from each other, and it makes for a very interesting life. So I really have no complaints at all."

Source: Wendy Smith, "Publishers Weekly Interviews Grace Paley," in Publishers Weekly, April 5, 1985, pp. 71-72.

SOURCES

Aarons, Victoria, "The Outsider Within: Women in Contemporary Jewish-American Fiction," in Contemporary Literature, Vol. 28, No. 3, Autumn 1987, pp. 378-93.

Bengtson, Vern L., "Beyond the Nuclear Family: The Increasing Importance of Multigenerational Bonds," in the Journal of Marriage and Family, Vol. 63, February 2001, pp. 1-16.

Bernstein, Adam, "Grace Paley: Acclaimed Short-Story Writer," in the Washington Post, August 24, 2007, p. B7.

Cohany, Sharon R., and Emy Sok, "Trends in Labor Force Participation of Married Mothers of Infants," Monthly Labor Review, February 2007, Vol. 130, No. 2, pp. 9-16.

Courtenay-Thompson, Fiona, and Kate Phelps, eds., The 20th Century Year by Year, Barnes & Noble, 1998, pp. 268-89.

"Global Warming," in the New York Times, http://topics.nytimes.com/top/news/science/topics/globalwarming/index.html?inline=nyt-classifier# (accessed May 26, 2008).

Harris, Robert R., "Pacifists with Their Dukes Up," in the New York Times Book Review, April 14, 1985, p. 7.

Hollington, Kris, "Assassination in the 21st Century," in Assassinology, http://www.assassinology.org/id21.html (accessed May 26, 2008).

Iannone, Carol, "A Dissent on Grace Paley," in Commentary, Vol. 80, No. 2, August 1985, pp. 54-8.

International Union for Conservation of Nature and Natural Resources, "IUCN Red List of Threatened Species," http://www.iucnredlist.org (accessed May 26, 2008).

Kamel, Rose, "To Aggravate the Conscience: Grace Paley's Loud Voice," in the Journal of Ethnic Studies, Vol. 11, No. 3, Fall 1983, pp. 29-49.

Kaminsky, Ilya, and Katherine Towler, "An Interview with Poet and Fiction Writer Grace Paley," in Poets & Writershttp://www.pw.org/content/interview_poet_and_fiction_writer_grace_paley (accessed April 16, 2008).

Krupnick, Mark, "Grace Paley: US Writer of Subtle and Discursive Short Stories, Poet, and ‘Combative Pacificist,’" in the Guardian, August 24, 2007, p. 44.

LaRossa, Ralph, "Fatherhood and Social Change," in Family Relations, Vol. 37, No. 4, October 1988, pp. 451-57.

Paley, Grace, "Anxiety," in Later the Same Day, Penguin, 1986, pp. 99-103.

———, "One Day I Made up a Story," in Just as I Thought, Farrar, Straus and Giroux, 1998, pp. 196-98; originally published in War Resisters Calendar, 1985.

———, "Other Mothers," in Feminist Studies, Vol. 4,No. 2, June 1978, pp. 166-69.

Ravits, Martha A. "The Jewish Mother: Comedy and Controversy in American Popular Culture," in MELUS, Vol. 25, No. 1, Spring 2000, pp. 3-31.

Remnick, David, "Grace Paley, Voice from the Village: The Short Story Writer, Composing with the Sounds of the City," in the Washington Post, April 14, 1985, p. C1.

Rothman, Ellen K., and Joyce Antler, "Mothering Heights: An Interview with the Author of a Cultural History of Jewish Mothers," in Mass Humanities, Fall 2007, http://www.mfh.org/newsandevents/newsletter/MassHumanities/Fall2007/mothering.html (accessed May 30, 2008).

Ruggles, Steven, and Susan Brower, "Measurement of Household and Family Composition in the United States, 1850-2000," in Population and Development Review, Vol. 29, No. 1, March 2003, pp. 73-101.

"Special Report: Accident in Japan," in Atomic Archive, http://www.atomicarchive.com/Reports/Japan/Accidents.shtml (accessed May 26, 2008).

Tyler, Anne, "Mothers in the City," in the New Republic, Vol. 192, No. 18, April 29, 1985, pp. 38-9.

Watts, Pauline, "Remembering Grace Paley," Web site of Sarah Lawrence College, http://www.slc.edu/grace-paley/index.php (accessed May 24, 2008).

FURTHER READING

Antler, Joyce, You Never Call! You Never Write! A History of the Jewish Mother, Oxford University Press, 2007.

This book uses humor and scholarship to dispel common stereotypes. Antler presents a study of the history of Jewish mothers, of women, and of Jewish life, and paints a picture of the culture that was so important to Paley's writing.

Arcana, Judith, Grace Paley's Life Stories: A Literary Biography, University of Illinois Press, 1993.

Arcana uses conversations with Paley and with her family and friends as the basis for a biographical study that links Paley's life with her writings.

Bach, Gerhard, and Blaine H. Hall, eds., Conversations with Grace Paley, University Press of Mississippi, 1997.

This text presents a collection of the many interviews that Paley gave during her long career, beginning in 1978 and continuing through 1995.

Cangro, Jacquelin, ed., The Subway Chronicles: Scenes from Life in New York, Plume, 2006.

This book is a collection of twenty-seven essays and humorous stories about life under the streets of New York. Paley based her stories on the people she observed in New York, and this collection also attempts to reveal what life is like in the Big Apple.

Coltrane, Scott, Family Man: Fatherhood, Housework, and Gender Equity, Oxford University Press, 1997.

This book presents an in-depth study of the role of the male in the family, as father and husband, and considers how parenting practices and the division of labor are divided in families.

Cosby, Bill, Fatherhood, Doubleday, 1986.

Bill Cosby's television show The Cosby Show provided an example of involved fathering that led viewers to think that most fathers were taking an active role in parenting during the 1980s. This book is a humorous and semi-autobiographical account of Cosby's experiences as a father and includes common advice about parenting.

Dans, Peter E., and Suzanne Wasserman, Life on the Lower East Side: Photographs by Rebecca Lepkoff, 1937-1950, Princeton Architectural Press, 2006.

This book is a collection of photographs that depicts the changing street and community scene in New York during the period in which Paley was growing up.

Lopate, Phillip, ed., Writing New York: A Literary Anthology, Library of America, 1998.

This book is an anthology of stories, letters, poems, essays, memoirs, and diaries that celebrate living in New York City.

Lucke, Margaret, Schaum's Quick Guide to Writing Great Short Stories, McGraw-Hill, 1998.

This text provides an easy-to-follow guide for writing stories. There are many tips for where to find story ideas, how to develop a plot, and how to create memorable characters.

Newhouse, Alana, ed. A Living Lens: Photographs of Jewish Life from the Pages of the Forward, W.W. Norton, 2007.

The Forward was a daily Yiddish newspaper with a circulation in 1920 that was greater than that of the New York Times. This book provides a visual examination of the world in which Paley grew up, the area where Jewish immigrants settled when they arrived in the United States early in the twentieth century.

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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

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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

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

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 at hand. Human anxiety involves an ability to use memory and imagination and to move backward and forward in time; 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.

Short-term anxiety can be considered within the range of normal human experience. It is only when anxiety presents with great intensity or long duration that it is classified as a pathological state. Particular manifestations of anxiety, such as a flashback experience, the development of a phobia, or the sudden onset of a panic attack, are suggestive of a serious anxiety problem.

Description

Although anxiety is something that everyone experiences 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 either 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. The term "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 outwardly nervous or anxious, or responds to others in an anxious manner.

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. Anxiety, on the other hand, is often vague and unfocused. 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.

Generalized anxiety disorder (GAD) is the common name for a clinically confirmed diagnosis of anxiety. GAD is defined as a state in which an individual has significant worry, fear, and anxiety for a majority of the time for a period of at least six months. The anxiety present in such an individual must produce at least three significant somatic symptoms, such as impaired concentration, sleep disturbance, muscle tension, irritability, increased fatigue, or restlessness.

GAD has been estimated to occur in 4% to 7% of the population at any given time in the United States. Females are about twice as likely as males to develop GAD. Nearly one-third of cases of GAD present before 11 years of age. Half of all cases have onset before 18 years of age.

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 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" reaction. This is the human organism's automatic response to a life-threatening situation, a state of physiological and emotional hyperarousal marked by high muscle tension and strong feelings of fear or anger. 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 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.

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.

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).

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 (such as 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. 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 without consciously knowing why.

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 proportion to its "cause." Prior to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), currently the model text for diagnostic criteria, 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 assert, for example, that the higher rates of phobias and panic disorders among women reflect 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 that 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, gastrointestinal problems, tingling, pale complexion, sweating, numbness, difficulty breathing or sleeping, 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, 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.

Diagnosis

The diagnosis of anxiety is difficult and complex because of the variety of causes and the highly personalized and individualized nature of its symptom formation. 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 normal. The doctor will then take the patient's medication, dietary, and occupational history to determine if they are taking prescription drugs that may 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, patient history is the most important source of diagnostic information. 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 performed 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.

The diagnosis of GAD is made when a person experiences anxiety coupled with physical symptoms that exists a majority of the time over a six-month period. The following conditions must be ruled out to confirm the GAD diagnosis:

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 predict 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 a 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 cause the anxiety.

ANXIOLYTICS. Most anxiolytic drugs (sometimes called tranquilizers) are either benzodiazepines or barbiturates. Barbiturates, once commonly used, are now rarely involved 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. Benzodiazepines are associated with a high rate of anxiety relapse if use is discontinued. Both drugs also increase the effects of alcohol and should never be taken in combination with it. Longeracting benzodiazepines, such as flurazepam and diazepam, should generally not be used in the elderly.

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 is not known to cause dependency, does not interact with alcohol, and does not affect the patient's ability to drive or operate machinery. Buspirone is also associated with a lower rate of relapse when use is discontinued. Buspirone is also far less likely to lead to tolerance over time than the benzodiazepines, so it is effective for a much longer period of time. 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, selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Paxil, are the treatment of choice. SSRIs are most commonly used to treat depression. Because anxiety often coexists with symptoms of depression, many doctors prescribe antidepressant medications for anxious/depressed patients. While SSRIs are more common, antidepressants, including tricyclic antidepressants such as imipramine (Tofranil) or monoamine oxidase inhibitors (MAO inhibitors) such as phenelzine (Nardil), are prescribed. The tricyclic antidepressants are also somewhat effective in relieving insomnia in many patients.

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. These 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 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. 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 heartbeat) 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. Biofeedback training is also used in an approach similar to relaxation training.

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 to be beneficial to patients with phobias and panic disorders. Hydrotherapy and aromatherapy can be useful to some anxious patients by promoting general relaxation of the nervous system. Yoga, aikido, tai chi, and dance therapy can help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

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. Success rates using pharmacologic therapy in patients with acute anxiety is between 50% and 70%. Success rates using antidepressants in patients with chronic or generalized anxiety are lower. Anxiety disorders typically involve a complex interaction of psychologic and physiologic factors. They are not easy to treat and do not disappear with great ease. Medications, behavioral techniques, and psychotherapy can be successful to varying degrees. The best outcomes occur when the anxiety-panic-phobia-depression cycle that is commonly found in these patients is disrupted. Anxiety should be viewed as a chronic condition that may involve an occasional increase in the severity of symptoms.

Health care team roles

Allied health personnel may be involved in the diagnosis and treatment of persons with anxiety at a variety of stages. Nurses will likely be involved in the initial interview of patients who present with anxiety. Psychological technicians may help conduct a more in-depth interview. Radiologic technicians play an important role in the process by conducting tests that help rule out conditions such as cardiovascular disease, hyperthyroidism, and myasthenia gravis. Nurse practitioners and physician assistants will often make the diagnosis of anxiety.

Pharmacists play a large role in the proper treatment of patients with anxiety because they dispense the drugs that are so important in the therapy of these patients. They also provide essential information on how to properly use these drugs to achieve peak effectiveness. Technicians may also be involved if the patient receives biofeedback, relaxation training, or cognitive-behavioral therapy.

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.

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. Some cognitive-behavioral techniques may be effective in preventing more serious anxiety when applied at an early stage.

Resources

BOOKS

"Anxiety." In Current Therapy. Conn, H.F., et al., eds. Philadelphia, PA: WB Saunders, 1998.

"Anxiety." In Ferri's Clinical Advisor. Edited by Fred F. Ferri. St. Louis, MO: Mosby, 2001.

"Anxiety Disorders." In Cecil Textbook of Medicine, 21st ed. Goldman, Lee and J. Claude Bennett, eds. Philadelphia, PA: WB Saunders, 2000

"Anxiety Disorders." In Harrison's Principles of Internal Medicine, 14th ed. New York, NY: McGraw-Hill, 1998.

"Generalized Anxiety Disorder." In Current Medical Diagnosis & Treatment, 40th ed. Reinhardt, S., J. Ransom, et al., eds. New York, NY: McGraw-Hill, 2001.

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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

See Language disorders

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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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Anxiety

Definition

Anxiety in humans is variously defined as an emotion or a physiological condition. It can be understood as a complex response to an object or event that arouses apprehension. Anxiety involves biochemical and neuromuscular changes in the body, memories of past events (including personal history), anticipation of future events, and appraisal of the present situation. In contrast to fear, which is a reaction to an immediate external physical threat (such as a fire, a dangerous animal or person, or a sudden, sharp pain ), anxiety is an unpleasant state of uneasiness that may not have a clear or obvious present cause—it can arise before a threat materializes and persist after the threat has passed. While animals clearly experience fear, as far as is known only humans undergo anxiety.

Description

Anxiety as a biochemical response to stress

In humans, the biochemical response to a stressful or anxiety-provoking situation is known as the “fight-or-flight” reaction. It begins with the activation of a section of the brain called the hypothalamic-pituitaryadrenal system, or HPA. This system first causes the release of steroid hormones, which are also known as glucocorticoids. These hormones include cortisol, the primary stress hormone in humans.

The HPA system then releases a set of neurotransmitters called catecholamines. The catecholamines include dopamine, norepinephrine, and epinephrine (also known as adrenaline). These compounds have three important effects:

  • Activation of the amygdala, an almond-shaped structure in the limbic system that triggers an emotional response of fear and anxiety.
  • Signaling the hippocampus, another part of the limbic system, to store the emotional experience in long-term memory. Humans develop the capacity to experience anxiety at some point between the ages of three and five, when long-term memory begins to store negative past events; this storage then triggers worry about future recurrences.
  • Suppressing activity in parts of the brain associated with short-term memory, concentration, and rational thinking. This suppression allows humans to react quickly to a stressful situation, but it also limits their ability to respond calmly and thoughtfully rather than emotionally.

Following the release of the catecholamines, a human's heart rate and blood pressure rise; the person breathes more rapidly, which allows the lungs to take in more oxygen. Blood flow to the muscles, lungs, and brain may increase by 300%–400%. The spleen releases more blood cells into the circulation, which increases the blood's ability to carry oxygen. The immune system redirects white blood cells to the skin, bone marrow, and lymph nodes; these are areas where injury or infection is most likely. At the same time, nonessential body systems shut down. The skin becomes cool and sweaty as blood is drawn away from it toward the heart and muscles. The mouth becomes dry, and the digestive system slows down; the person may feel queasy or nauseated.

Some degree of anxiety is adaptive in humans; it helps them to prepare for the future and devise strategies to prevent or lower the risk of dangerous or stressful situations. For example, a person who is anxious about a hurricane forecast is motivated to purchase food and secure their house or consider evacuating. On the other hand, too much anxiety is harmful because it interferes with psychological as well as physical functioning. If anxiety is not relieved within a reasonable period of time, the organ systems of the body do not have the opportunity to return fully to normal levels. Different organs become under- or overactivated on a long-term basis. In time, these abnormal levels of activity can damage the body.

State and trait anxiety

People vary in their susceptibility to anxiety on the basis of temperament and possibly other genetic factors. A psychologist named Spielberger introduced a useful distinction between what he called state and trait anxiety in the early 1970s. State anxiety refers to the unpleasant physical sensations associated with fear experienced in the face of a threat, as described earlier. The threat can be physical, psychological, or both. State anxiety implies a cognitive evaluation; a person experiencing this type of anxiety must believe on some level that a specific situation is in fact dangerous or threatening. Typically, the person feels less anxious after the stressful event is over.

Trait anxiety, on the other hand, refers to an aspect of personality—namely, a tendency to experience state anxiety when confronted with a threat—that remains stable in a specific individual over time but varies from one individual to another. In other words, some people are more susceptible than others to feel anxious in response to low-level threats or stressors.

Anxiety disorders

The experience of anxiety as such is not considered a mental disorder; it is usually described as a syndrome (cluster or group of symptoms) or condition. Long-term anxiety coupled with genetic vulnerability, however, leads to a number of disorders grouped together by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) as anxiety disorders. These disorders are defined as conditions lasting six months or longer and as causing significant impairment in the patient's social or occupational functioning. They include:

  • Panic disorder. Panic disorder is characterized by sudden episodes of intense anxiety accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. The physical symptoms associated with panic disorder may cause the senior to think he or she is having a heart attack, is going crazy, or is about to die.
  • Generalized anxiety disorder (GAD). GAD is one of the more common anxiety disorders among older adults. It is characterized by an anxious feeling that persists even though the anxiety may not have a specific focus or trigger. The person with GAD spends a lot of time worrying about everyday problems (family issues, money worries, minor health problems, etc.)
  • Obsessive-compulsive disorder (OCD). People with OCD are afflicted by anxiety provoking thoughts, ideas, or impulses (obsessions) and by repetitive or ritualistic behaviors (compulsions) that are done to lessen the anxiety. Compulsions include such actions as repeated hand washing, counting items, checking door locks several times over, etc.
  • Social phobia. Social phobia refers to extreme fear of social or performance-related situations to the point that functioning is impaired. The anxiety may be limited to a specific situation (such as public speaking) or it may extend to almost any activity outside the patient's family.
  • Specific phobias. A specific phobia is an intense fear of an object or situation that does not ordinarily pose a real danger. Common phobias are fear of flying, small closed spaces (such as elevators or tunnels), water, dogs, high places, highway driving, bridges, and injuries involving blood. Most people with specific phobias recognize that their fear is excessive or unfounded.
  • Post-traumatic stress disorder (PTSD). PTSD is an anxiety disorder in which an overwhelming traumatic event (criminal or terrorist attack, transportation disaster, natural disaster, etc.) is reexperienced in the form of flashbacks and nightmares. The person with PTSD typically avoids places or persons that remind them of the horrifying event.

Demographics

Primary anxiety disorders are common in the general adult population in North America. According to the National Institute of Mental Health (NIMH), about 40 million Americans, or 18 percent of the adult population, meet the criteria for an anxiety disorder in any given year. As far as is known, all races and ethnic groups are equally affected. The female: male ratio is about 3:2.

Seniors, however, are more likely to experience anxiety that does not meet the criteria of an anxiety disorder. Anxiety in older adults is more likely to be associated with depression , physical illness, bereavement, other life changes, dementia, or delirium rather than a primary anxiety disorder. It is relatively uncommon for seniors to develop anxiety disorders for the first time, with the exception of PTSD. The most common primary anxiety disorder in seniors is GAD, which may affect as many as 3 percent of older adults. PTSD can occur in adults in any age group exposed to a sufficiently traumatic event. OCD, social phobia, and panic disorder are more common in younger adults than in the elderly, and often become less severe with age.

Causes and symptoms

Causes

The causes of anxiety are the complex interactions between the human central nervous system, the human capacity to remember the past and anticipate the future, an individual's genetic susceptibility to stress, his or her life history, and specific situational cues or triggers.

Symptoms

People experiencing anxiety may have some or many of the following physical symptoms:

  • Digestive system: dry mouth, nausea, vomiting, diarrhea, abdominal cramps.
  • Respiratory system: dizziness, fainting, choking sensations, shortness of breath, difficulty breathing.
  • Circulatory system: rapid pulse or heartbeat, irregular heart rhythms, headache, heavy sweating.
  • Musculoskeletal system: muscle tension or cramps, chest pain, shakiness and impaired coordination, general fatigue, stiff or sore joints.
  • Other: Insomnia, restlessness, pacing the floor.

Diagnosis

The diagnosis of anxiety is complicated by a number of factors. Because anxiety is a condition or syndrome rather than a disease or disorder in its own right, the doctor will need to distinguish between anxiety as a temporary response to a specific situation or event; anxiety as a symptom of a physical illness, dementia, a sleep disorder, drug or alcohol withdrawal, or a medication side effect; and anxiety as a symptom of a primary anxiety disorder.

History and physical examination

The senior's doctor will usually take the following steps:

  • History-taking and interview. The doctor will ask the patient to describe his or her anxiety experiences, and will note whether they are acute (lasting hours to weeks) or persistent (lasting from months to years). A family history may be taken, as many anxiety disorders tend to run in families. The doctor may also give the patient a diagnostic questionnaire to evaluate the presence of anxiety disorders. The Hamilton Anxiety Scale is a commonly used instrument for evaluating anxiety in seniors.
  • Medical evaluation. This step is necessary because new-onset anxiety in an older adult is frequently caused by such physical disorders as hyperthyroidism, Cushing's disease, mitral valve prolapse, carcinoid syndrome, and pheochromocytoma. The doctor will also observe the patient for such external physical signs of anxiety as sweating, tremor, speeded-up heartbeat, or rapid breathing. In addition, certain medications (steroids, digoxin, thyroxine, theophylline, and selective serotonin reuptake inhibitors or SSRIs) may also cause anxiety as a side effect. The senior should be asked about his or her use of coffee, tea, and herbal preparations as well, since beverages containing high levels of caffeine can cause jitteriness and anxious feelings in older adults.
  • Substance abuse evaluation. Because anxiety is a common symptom of substance abuse and withdrawal syndrome, the doctor will ask about the patient's use of nicotine, alcohol, and other common substances (including prescription medications) that may be abused. In addition, some seniors use alcohol or other drugs as a form of self-treatment for underlying anxiety, so that the doctor will need to determine whether the anxiety is causing the alcohol or drug use, or the substance abuse is causing the anxiety.
  • Evaluation for other psychiatric disorders. This step is necessary because of the frequent overlapping between anxiety and depression in older adults. In addition, some older adults meet the DSM-IV criteria for more than one anxiety disorder.

Laboratory tests

The doctor may order one or more blood or urine tests to rule out substance abuse disorders, disorders of the thyroid gland, HIV infection, or infections affecting the central nervous system (encephalitis, latestage syphilis, meningitis ). An electrocardiogram (ECG) or treadmill test may be given to rule out cardiac disorders.

Imaging studies

Imaging studies are usually performed only if the doctor needs to rule out brain tumors , an infection of the brain, a skull fracture, or other physical abnormalities that may be causing the anxiety.

Treatment

Medications

Medications are generally given to seniors whose anxiety is severe enough to interfere with their daily life:

  • Benzodiazepines. This group of tranquilizers does not decrease worry, but lowers the senior's anxiety by decreasing muscle tension. The benzodiazepines have three major disadvantages, however: they carry a high risk of dependence; they cannot be given to seniors who abuse alcohol or other drugs; and they affect short-term memory. In addition, they can cause drowsiness and loss of coordination, which can increase the risk of falls.
  • Tricyclic antidepressants. These drugs include imipramine (Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin). Their major drawback for seniors is that, like the benzodiazepines, they increase the patient's risk of falls and other accidents.
  • Selective serotonin reuptake inhibitors. Paroxetine (Paxil), one of the SSRIs, was approved by the Food and Drug Administration (FDA) in 2001 as a treatment for GAD. Venlafaxine (Effexor) is effective in treating patients whose anxiety symptoms are primarily somatic. It is important for seniors taking an SSRI not to discontinue the drug abruptly, as it increases the risk of suicide.

A newer drug, pregabalin (sold under the trade name Lyrica in the United States), has been approved by the Food and Drug Administration for the treatment of fibromyalgia and partial seizures. It is also approved in Europe (though not in the United States as of early 2008) for the treatment of GAD. Early trials indicate that pregabalin is effective in treating seniors with GAD; it has a low rate of interactions with other drugs, a low risk of dependence, and relieves anxiety symptoms more rapidly than the SSRIs. Its major drawback is an increased risk of drowsiness and loss of balance.

Patient education and psychotherapy

Patient education is an important first step in treating anxiety, whether or not the senior meets the formal criteria for an anxiety disorder. The doctor may have an office handout on anxiety or offer patient education materials from the Anxiety Disorders Association of America (ADAA) or the National Institute of Mental Health (NIMH). These brochures are written in a simple, easy-to-understand style and make it easier for the senior (or caregiver ) to ask the doctor questions about the senior's specific difficulties with anxiety and the doctor's treatment recommendations.

QUESTIONS TO ASK YOUR DOCTOR

  • How can I tell whether worry or anxious feelings are appropriate or excessive?
  • What are the indications that I may have an anxiety disorder?
  • What actions or activities would you recommend for dealing with normal anxiety?

A number of evidence-based studies have found cognitive therapy to be effective in treating chronic anxiety. Relaxation training is another psychological intervention that has been shown to help seniors. The greatest benefit of cognitive therapy is its effectiveness in helping seniors with the disorder to learn more realistic ways to appraise their problems and to use better problem-solving techniques. As a rule, however, anxious patients who have concurrent personality disorders ; who are in the early stages of cognitive decline; who are living with chronic social stress (e.g., caring for a spouse with Alzheimer's disease or living in an unsafe neighborhood); or who don't trust psychotherapy require treatment with medications.

Exposure therapy is the treatment most commonly recommended for social phobia and specific phobias. In exposure therapy, the patient is gradually exposed to the object or situation that is feared, perhaps at first only through pictures or tapes, then later in real life. For example, a senior who is afraid of dogs may begin by looking at a picture of a dog, then watch a short video of a dog, then visit someone with a well-behaved pet dog, and finally touch or pet a dog. Often the therapist will accompany the person to a feared situation to provide support and guidance.

Family therapy is sometimes recommended for seniors who are living with an adult son or daughter and whose anxiety is causing stress for other members of the household.

Group therapy or informal anxiety support groups are also recommended for seniors with anxiety disorders. In many cases, social contact with others eases the isolation that often reinforces the senior's anxiety, and group members often have helpful tips about coping with the stresses that cause worry as well as with the worry itself.

Complementary and alternative (CAM) approaches

Several alternative and complementary therapies have been found helpful in treating patients with diagnosed anxiety disorders. These include hypnotherapy; music therapy; yoga; t'ai chi ; religious practice; mindfulness meditation; and guided imagery meditation. One herbal remedy that has been used in clinical trials for anxiety is passionflower (Passiflora incarnata). The researchers reported that passionflower extract was as effective as a benzodiazepine tranquilizer in relieving feelings of anxiety without the side effects of the prescription medication.

Nutrition/Dietetic concerns

The senior's eating patterns should be evaluated for adequate nutritional balance, regular mealtimes (no skipping meals), and high levels of caffeine intake. This evaluation is particularly important if the senior is abusing alcohol or other drugs to cope with anxiety, as substance abuse often leads to malnutrition in older adults. In some cases a vitamin B 12 supplement may help, as a deficiency of this vitamin causes anxiety and depression in some older people. Seniors who smoke should be encouraged to quit, as the nicotine in tobacco has a stimulant effect.

Regular physical exercise alongside a well-balanced diet is often recommended to relieve anxiety and counteract the effects of emotional stress on the body.

Therapy

Therapy for anxiety may include a short course of medication, longer-term psychotherapy, patient education, or a combination of all three. The doctor may also recommend relaxation techniques or other CAM approaches.

Prognosis

The prognosis of anxiety as a temporary response to a time-limited crisis is generally very good; most people, including seniors, return to a normal level of functioning within hours or a few days after the event has passed. The prognosis for recovery from an anxiety disorder depends on the specific anxiety disorder and its severity; the availability of family or social support; the senior's living situation; and the presence of other diseases or disorders, particularly chronic health conditions.

KEY TERMS

Amygdala —An almond-shaped brain structure in the limbic system that is activated in acute stress situations to trigger the emotion of fear.

Cortisol —A steroid hormone released by the cortex (outer portion) of the adrenal gland when a person is anxious.

Cue —A stimulus, either internal body sensations or an external event or object, that causes a learned response in an individual. Cues are sometimes called triggers.

Free-floating —A term used in psychiatry to describe anxiety that is unfocused or lacking an apparent cause or object.

Hippocampus —A curved ridge in the brain that is part of the limbic system. The hippocampus stores long-term memories of anxiety-provoking experiences.

Panic attack —An episode of intense fear, abrupt in onset, lasting for several minutes, and accompanied by physical symptoms and/or temporary cognitive disturbances. Panic attacks may be unexpected, or they may be cued.

Phobia —An unfounded or unrealistic dread of a specific object or situation that arouses feelings of panic.

State anxiety —The immediate physical sensations associated with perception of a threat and the resulting fear response.

Syndrome —A group of signs or symptoms that occur together and characterize a specific disease or condition.

Temperament —The dimension of an individual's personality that is rooted in genetic or biological factors.

Trait anxiety —An aspect of an individual's personality that influences their susceptibility to anxiety in stressful situations.

Worry —Mental distress or agitation, usually about something anticipated in the future.

Prevention

As of 2008, the genetic factors involved in trait anxiety or the DSM-IV anxiety disorders have not been fully identified. In addition, the many stressors of modern life that raise anxiety levels in older adults are difficult to escape or avoid. The best preventive strategy, given that trait anxiety may be innate and that chronic worrying often starts early in life, is for parents to model realistic assessment of stressful events and teach effective coping strategies to their children.

Caregiver concerns

Care givers of anxious seniors should be concerned about:

  • The long-term effects of worry and anxiety on the senior's physical health.
  • The impact of chronic anxiety or a diagnosed anxiety disorder on other family members. Many books on caring for seniors note that chronic worrying on the part of the older person can be stressful for others sharing a home with them.
  • Suicidal ideation or completed suicide. Seniors suffering from depression along with anxiety or a diagnosed anxiety disorder are at increased risk of self-harm.
  • Proper use of any medications prescribed for anxiety. Benzodiazepines carry a risk of addiction, abuse, or short-term memory loss, while sudden discontinuation of an SSRI may increase the senior's risk of suicide.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 34, “Anxiety Disorders.” Whitehouse Station, NJ: Merck, 2005.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, “CAM Therapies for Specific Conditions: Anxiety.” New York: Simon & Schuster, 2002.

Spielberger, C. D. Anxiety: Current Trends in Theory and Research: I. New York: Academic Press, 1972.

PERIODICALS

Ayers, C. R., et al. “Evidence-Based Psychological Treatments for Late-Life Anxiety.” Psychology and Aging 22 (March 2007): 8–17.

Kroenke, K., R. L. Spitzer, J. B. Williams, et al. “Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection.” Annals of Internal Medicine 146 (March 6, 2007): 317–325.

Longo, Lance, and Brian Johnson. “Addiction: Part I. Benzodiazepines—Side Effects, Abuse Risk and Alternatives.” American Family Physician 61 (April 1, 2000): 2121–2128.

Shearer, Steven, and Lauren Gordon. “The Patient with Excessive Worry.” American Family Physician 73 (March 15, 2006): 1049–1056.

OTHER

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 06-3879. Bethesda, MD: NIMH, 2006.

Xiong, Glen L., and James O. Bourgeois. “Hypochondriasis.” eMedicine, November 20, 2007. http://www.emedicine.com/med/topic3122.htm [cited March 21, 2008].

Yates, William R., MD. “Anxiety Disorders.” eMedicine, August 23, 2007. http://www.emedicine.com/med/topic152.htm [cited March 21, 2008].

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org/.

Anxiety Disorders Association of America (ADAA)., 8730 Georgia Avenue, Suite 600, Silver Spring, MD, 20910, (240) 485-1001, (240) 485-1035, http://www.adaa.org/.

National Alliance on Mental Illness (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201, (703) 524-7600, (800) 950-NAMI (6264), (703) 524-9094, http://www.nami.org/Hometemplate.cfm.

National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443-4279, [email protected], http://www.nimh.nih.gov/index.shtml.

National Mental Health Association (NMHA), 2000 N. Beauregard Street, 6th Floor, Alexandria, VA, 22311, (703) 684-7722, (800) 969-NMHA, (703) 684-5968, http://www1.nmha.org/.

Rebecca J. Frey Ph.D.

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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 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

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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.

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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

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