Behavioral, medical approaches can treat anxiety disorders 12/22/2006 – SEVERAL readers have written about various aspects of anxiety disorders. In response, this and the next column will be devoted to these common and often devastating problems.
Stress, fear, and anxiety all tend to be interactive. The principal components of anxiety are psychological (tension, fears, nervousness, irritability, difficulty in concentration, apprehension) and somatic (rapid heart rate, chest pain, hyperventilation, tremor, sweating, hot or cold flashes).
Other symptoms include nausea or abdominal distress, fatigue and sleep disturbances. Depression complicates the clinical course of anxiety in more than 50 percent of patients. The following are some of the major disorders.
Generalized Anxiety Disorder
This is the most common of the clinically significant anxiety disorders. It is characterized by excessive worry that is difficult to control; is out of proportion to any realistic concern about family, work, finances or health; and persists on a daily basis for at least six months.
Generalized anxiety disorder typically begins between ages 20 and 35 and consists of disabling symptoms such as apprehension, worry, irritability and hypervigilance (preparation for threat) coupled with such somatic complaints as elevated blood pressure and rapid heart rate (tachycardia), abdominal pain and ulcer symptoms, fatigue, muscle tension, headache, fainting spells and sleep disturbance.
The hallmark is the panic attack, an intense episode of fear or discomfort that develops abruptly, rises to a peak within 10 minutes and is associated with a set of somatic symptoms.
To qualify as panic disorder, a panic attack must occur unexpectedly, be recurrent (at least once a month) and be associated with significant and persistent worry about having another attack or the consequences of having another attack (dying, going crazy). Recurrent sleep panic attacks (not nightmares) occur in about 30 percent of patients with panic disorder. Anticipatory anxiety develops in all these patients and further constricts their daily lives.
Panic disorder tends to run in families, usually begins before age 25 and may affect up to 5 percent of the population. Women are twice as likely to be affected as men and are especially susceptible during the premenstrual period. Suicide attempts are as frequent in panic disorder as in major depression.
At least 40 percent of people with panic disorder develop agoraphobia.
Agoraphobics have a morbid fear of public places and avoid situations from which they perceive escape to be difficult or embarrassing. Those who develop agoraphobia in early adult life may find it impossible to pursue a normal life.
Social phobia is a marked and persistent fear of one or more social or performance situations, in which the individual fears that he or she will act in a way or show anxiety that will be humiliating or embarrassing.
Anticipation of entering such situations often provokes the psychological symptoms of anxiety or panic and such somatic symptoms as flushing or blushing, sweaty palms or tremors. Therefore, the affected person tries desperately to avoid social situations; if unable to escape, they must endure profound discomfort.
Unlike mere shyness, social phobia is marked by its severity, its associated somatic symptoms and especially by the degree of functional impairment.
Obsessions are persistent and intrusive ideas, impulses or images. Compulsions are repetitive behaviors such as hand-washing, checking or mental repetitive acts such as praying, counting and repeating words or phrases silently. The affected person recognizes that the obsessions and compulsions are absurd and tries to resist them, but anxiety is only relieved by ritualistic performance of the action or by deliberate contemplation of the intruding idea or emotion. Patients with obsessions or compulsions may be severely disabled by them, spending several hours per day in such preoccupations.
There is some overlap of obsessive-compulsive disorder with other behaviors such as tics, hair-pulling, nail-biting, hypochondriasis (always thinking one is sick), Tourette’s syndrome and eating disorders.
Major depression occurs in about two-thirds of these patients during their lifetimes. The highest rates of OCD occur in the young, divorced, separated and unemployed.
Neurologic abnormalities of fine motor coordination and involuntary movements are common. Under extreme stress, these individuals sometimes exhibit paranoid and delusional behaviors that are often associated with depression, a pattern of symptoms that can mimic schizophrenia.
Post-Traumatic Stress Disorder
This occurs in up to half of individuals who have been exposed to events in which they have experienced or witnessed a highly threatening or dangerous event. As a consequence, an affected person develops flashbacks, nightmares, emotional numbing, insomnia and prominent anxiety symptoms.
Anxiety disorders can be treated with various medications, primarily antidepressants and the benzodiazepines (one of which is Valium). Behavioral approaches and relaxation techniques may be helpful in reducing anxiety. In desensitization, the patient is exposed to graded doses of a feared object or situation.
Visual imagery is a technique in which the patient imagines the anxiety-provoking situation while at the same time learning to relax. The concept is that the patient will then suffer less anxiety when facing the real-life situation.
Psychotherapy can be of value in treating persons with anxiety disorders. Group therapy is the treatment of choice when the anxiety is clearly a function of the patient’s difficulties in dealing with others. Peer support groups for panic disorder and agoraphobia have been particularly valuable. Family counseling may aid acceptance of the patient’s symptoms.
Anxiety disorders are usually of long standing and may be difficult to treat. Nevertheless, all can be relieved to varying degrees with medications and behavioral techniques.
Virgil Williams and Ron Eisenberg are staff physicians at Highland General Hospital in Oakland. Their column runs Mondays in Bay Area Living. To read past columns or other health and fitness stories, visit http://www.insidebayarea.com/health.