2.16: 2.23 Anxiety Disorders
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Anxiety Disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated.
Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.
Panic Disorders
“For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I’m losing control in a very extreme way. My heart pounds really hard, I feel like I can’t get my breath, and there’s an overwhelming feeling that things are crashing in on me.”
“It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying.”
“In between attacks there is this dread and anxiety that it’s going to happen again. I’m afraid to go back to places where I’ve had an attack. Unless I get help, there soon won’t be anyplace where I can go and feel safe from panic.”
Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.
A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.
Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.
Obsessive-Compulsive Disorder
“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.”
"I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”
“Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.”
People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.
For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.
Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.
OCD affects about 2.2 million American adults, and the problem can be accompanied by eating disorders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.
Post-Traumatic Stress Disorder
“I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.”
“Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.”
“The rape happened the week before Thanksgiving, and I can’t believe the anxiety and fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I can’t relax, can’t sleep, don’t want to be with anyone. I wonder whether I’ll ever be free of this terrible problem.”
Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.
People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping.
Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.
Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.
PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.
Social Phobia (Social Anxiety Disorder)
“In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick in my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.”
“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.”
Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.
While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.
Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.
Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.
Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence. There is some evidence that genetic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety.
A specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.
Specific phobias affect an estimated 19.2 million adult Americans and are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.
Generalized Anxiety Disorder (GAD)
“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.”
“When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment."
“I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were. When I got a stomachache, I’d think it was an ulcer.”
People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.
GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. People with GAD can’t seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can’t relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.
When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don’t avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe. GAD affects about 6.8 million American adults, including twice as many women as men. The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age. There is evidence that genes play a modest role in GAD.
Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.
Treatment of Anxiety Disorders
In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.
People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.
Often people believe that they have “failed” at treatment or that the treatment didn’t work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.
Personality Disorders
Personality disorders are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work. People with personality disorders have difficulty dealing with everyday stresses and problems. They often have stormy relationships with other people. The exact cause of personality disorders is unknown. However, genes and childhood experiences may play a role. Symptoms vary widely depending on the specific type of personality disorder. Treatment usually includes talk therapy and sometimes medicine.
Borderline Personality Disorder
Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed borderline personality disorder as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses. Because some people with severe borderline personality disorder have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet. Most people who have borderline personality disorder suffer from:
- Problems with regulating emotions and thoughts
- Impulsive and reckless behavior
- Unstable relationships with other people
People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides. According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have borderline personality disorder in a given year. Borderline personality disorder is often viewed as difficult to treat. However, recent research shows that borderline personality disorder can be treated effectively, and that many people with this illness improve over time.
According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
- Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
- A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
- Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
- Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating.
- Recurring suicidal behaviors or threats or self-harming behavior, such as cutting Intense and highly changeable moods, with each episode lasting from a few hours to a few days
- Chronic feelings of emptiness and/or boredom. Inappropriate, intense anger or problems controlling anger
- Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Seemingly mundane events may trigger symptoms. For example, people with borderline personality disorder may feel angry and distressed over minor separations — such as vacations, business trips, or sudden changes of plans —from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.
Schizophrenia
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected. The illness usually emerges in young people in their teens or twenties. Although children over the age of five can develop schizophrenia, it is rare before adolescence. In children, the disease usually develops gradually and is often preceded by developmental delays in motor or speech development. Childhood-onset schizophrenia tends to be harder to treat and has a less favorable prognosis than does the adult-onset form.
The Symptoms of schizophrenia:
There are many myths and misconceptions about schizophrenia. Schizophrenia is not a multiple or split personality, nor are individuals who have this illness constantly incoherent or psychotic. Although the media often portray individuals with schizophrenia as violent, in reality, very few affected people are dangerous to others. In fact, individuals with schizophrenia are more likely to be victims of violence than violent themselves. Schizophrenia has severe symptoms. A diagnosis of schizophrenia requires that at least two of the symptoms below be present during a significant portion of a one-month period: delusions (false beliefs such as conspiracies, mind control, or persecution); hallucinations (usually voices criticizing or commenting on the person’s behavior); disorganized speech (incomprehensible or difficult to understand); grossly disorganized or catatonic behavior; and negative symptoms such as flat emotions, lack of facial expressions, and inattention to basic self-care needs such as bathing and eating.
However, the presence of either one of the first two symptoms is sufficient to diagnose schizophrenia if the delusions are especially bizarre or if the hallucinations consist of one or more voices that keep a running commentary on the person’s behavior or thoughts. The DSM-IV specifies additional criteria for a diagnosis of schizophrenia: occupational dysfunction, persistence of the disturbance for at least six months, exclusion of a mood disorder, exclusion of a substance-abuse or medical condition that causes similar symptoms, and consideration of a possible pervasive developmental disorder. The course of schizophrenia varies considerably from one individual to the next. Most people who have schizophrenia experience at least one, and usually more, relapses after their first psychotic episode. Relapses are periods of more intense symptoms of illness (hallucinations and delusions). During remissions, the negative symptoms related to emotion or personal care are usually still present. About 10 percent of patients remain severely ill for long periods of time and do not return to their previous state of mental functioning. Several long-term studies found that as many as one-third to one-half of people with schizophrenia improve significantly or even recover completely from their illness.
The Causes of Schizophrenia
Like the other mental illnesses discussed here, scientists are still working to determine what causes schizophrenia. Also like the other mental illnesses, genetic and environmental factors most likely interact to cause the disease. Several studies suggest that an imbalance of chemical neurotransmitter systems of the brain, including the dopamine, GABA, glutamate, and norepinephrine neurotransmitter systems, are involved in the development of schizophrenia. Family, twin, and adoption studies support the idea that genetics plays an important role in the illness. For example, children of people with schizophrenia are 13 times more likely, and identical twins are 48 times more likely, to develop the illness than are people in the general population. Scientists continue to look at genes that may play a role in causing schizophrenia. One gene of interest to scientists who study schizophrenia codes for an enzyme that breaks down dopamine in the synapse.
Treating Schizophrenia
There is no cure for schizophrenia; however, effective treatments that make the illness manageable for most affected people are available. The optimal treatment includes antipsychotic medication combined with a variety of psychotherapeutic interventions. Since the 1950s, doctors have used antipsychotic drugs, such as chlorpromazine and haloperidol, to relieve the hallucinations and delusions typical of schizophrenia. Recently, newer (also called atypical) antipsychotic drugs such as risperidone and clozapine have proven to be more effective. Early and sustained treatment that includes antipsychotic medication is important for long-term improvement of the course of the disease. Patients who discontinue medication are likely to experience a relapse of their illness. People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training). Therapies that combine family and community support, education, and behavioral and cognitive skills to address specific challenges help schizophrenic patients improve their functioning and the quality of their lives.
Suicide and Self-harm
Suicide is among the most common causes of death in the United States. People may consider suicide when they are hopeless and can't see any other solution to their problems. Often it's related to serious depression, alcohol or substance abuse, or a major stressful event.
People who have the highest risk of suicide are white men. But women and teens report more suicide attempts. If someone talks about suicide, you should take it seriously. Urge them to get help from their doctor or the emergency room, or call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Therapy and medicines can help most people who have suicidal thoughts. Treating mental illnesses and substance abuse can reduce the risk of suicide.
Suicidal behavior is complex. Some risk factors vary with age, gender, or ethnic group and may occur in combination or change over time. Suicide is a major, preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. The overall rate was 11.3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death.
In 2007, suicide was the third leading cause of death for young people ages 15 to 24. As in the general population, young people were much more likely to use firearms, suffocation, and poisoning than other methods of suicide, overall. However, while adolescents and young adults were more likely to use firearms than suffocation, children were dramatically more likely to use suffocation.
There were also gender differences in suicide among young people, as follows:
- Nearly five times as many males as females ages 15 to 19 died by suicide.
- Just under six times as many males as females ages 20 to 24 died by suicide.
Research shows that risk factors for suicide include:
- depression and other mental disorders, or a substance-abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors.
- prior suicide attempt
- family history of mental disorder or substance abuse
- family history of suicide
- family violence, including physical or sexual abuse
- firearms in the home, the method used in more than half of suicides
- incarceration
- exposure to the suicidal behavior of others, such as family members, peers, or media figures.
However, suicide and suicidal behavior are not normal responses to stress; many people have these risk factors, but are not suicidal. Research also shows that the risk for suicide is associated with changes in brain chemicals called neurotransmitters, including serotonin. Decreased levels of serotonin have been found in people with depression, impulsive disorders, and a history of suicide attempts, and in the brains of suicide victims. Public health approaches to preventing suicide include establishing telephone crisis hot lines, restricting access to suicide methods (for example, firearms), counseling media to reduce “copycat” suicides, screening teens for risk factors of suicide, and training professionals to improve recognition and treatment of mood disorders. Research about the effectiveness of these methods indicates that the screening and training strategies are more helpful for preventing suicides among young people than the other methods are.