Anxiety

Anxiety is a complex combination of negative emotions that includes fear, apprehension and worry, and is often accompanied by physical sensations such as palpitations, nausea, chest pain and/or shortness of breath.

Anxiety is often described as having cognitive, somatic, emotional, and behavioral components (Seligman, Walker & Rosenhan, 2001). The cognitive component entails expectation of a diffuse and uncertain danger. Somatically the body prepares the organism to deal with threat (known as an emergency reaction); blood pressure and heart rate are increased, sweating is increased, bloodflow to the major muscle groups is increased, and immune and digestive system functions are inhibited. Externally, somatic signs of anxiety may include pale skin, sweating, trembling, and pupillary dilation. Emotionally, anxiety causes a sense of dread or panic and physically causes nausea, and chills. Behaviorally, both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety. These behaviors are frequent and often maladaptive, being most extreme in anxiety disorders. However, anxiety is not always pathological or maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it has a very important function in relation to survival.

Neural circuitry involving the amygdala and hippocampus is thought to underlie anxiety (Rosen & Schulkin, 1998). When confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased bloodflow in the amygdala (Zald & Pardo, 1997; Zald, Hagen & Pardo, 2002). In these studies, the participants also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially harmful behaviors such as feeding on rotten food.

A chronically recurring case of anxiety that has a serious effect on a person's life may be clinically diagnosed as an anxiety disorder. The most common are generalized anxiety disorder, panic disorder, social anxiety disorder, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder (PTSD).

Diagnosis
A good assessment is essential for the initial diagnosis of an anxiety disorder, preferably using a standardized interview or questionnaire procedure alongside expert evaluation and the views of the person themselves. There should be a medical examination in order to identify possible medical conditions that can cause the symptoms of anxiety. A family history of anxiety disorders is suggestive of the possibility of an anxiety disorder.

Generalized anxiety disorder
Generalized anxiety disorder is a common chronic disorder that affects twice as many women as men and can lead to considerable impairment (Brawman-Mintzer & Lydiard, 1996, 1997). As the name implies, generalized anxiety disorder is characterized by long-lasting anxiety that is not focused on any particular object or situation. In other words it is unspecific or free-floating. People with this disorder feel afraid of something but are unable to articulate the specific fear. They fret constantly and have a hard time controlling their worries. Because of persistent muscle tension and autonomic fear reactions, they may develop headaches, heart palpitations, dizziness, and insomnia. These physical complaints, combined with the intense, long-term anxiety, make it difficult to cope with normal daily activities.

Panic disorder
In panic disorder, a person suffers brief attacks of intense terror and apprehension that cause trembling and shaking, dizziness, and difficulty breathing. One who is often plagued by sudden bouts of intense anxiety might be said to be afflicted by this disorder. The American Psychiatric Association (2000) defines a panic attack as fear or discomfort that arises abruptly and peaks in 10 minutes or less.

Although panic attacks sometimes seem to occur out of nowhere, they generally happen after frightening experiences, prolonged stress, or even exercise. Many people who have panic attacks (especially their first one) think they are having a heart attack and often end up at the doctor or ER. Even if the tests all come back normal the person will still worry, with the physical manifestations of anxiety only reinforcing their fear that something is wrong with their body. Extreme awareness of every little thing that happens or changes with their body can make for a stressful time.

Normal changes in heartbeat, such as when climbing a flight of stairs will be noticed by a panic sufferer and lead them to think something is wrong with their heart or they are about to have another panic attack. Some begin to worry excessively and even quit jobs or refuse to leave home to avoid future attacks. Panic disorder can be diagnosed when several apparently spontaneous attacks lead to a persistent concern about future attacks. A common complication of panic disorder is agoraphobia -- anxiety about being in a place or situation where escape is difficult or embarrassing (Craske, 2000; Gorman, 2000).

Phobia
This category involves a strong, irrational fear and avoidance of an object or situation. The person knows the fear is irrational, yet the anxiety remains. Phobic disorders differ from generalized anxiety disorders and panic disorders because there is a specific stimulus or situation that elicits a strong fear response. A person suffering from a phobia of spiders might feel so frightened by a spider that he or she would try to jump out of a speeding car to get away from one.

People with phobias have especially powerful imaginations, so they vividly anticipate terrifying consequences from encountering such feared objects as knives, bridges, blood, enclosed places, or certain animals. These individuals generally recognize that their fears are excessive and unreasonable but are generally unable to control their anxiety.

In addition to specific phobias, such as fears of knives, rats or spiders, there is another category of phobias known as social phobias. Individuals with this disorder experience intense fear of being negatively evaluated by others or of being publicly embarrassed because of impulsive acts. Almost everyone experiences "stage fright" when speaking or performing in front of a group. But people with social phobias become so anxious that performance is out of the question. In fact, their fear of public scrutiny and potential humiliaton becomes so pervasive that normal life can become impossible (den Boer 2000; Margolis & Swartz, 2001). Another social phobia is love-shyness, which most adversely affects certain men. Those afflicted find themselves unable to initiate intimate adult relationships (Gilmartin 1987).

Obsessive-compulsive disorder
Obsessive compulsive disorder is a type of anxiety disorder characterized by obsessions and/or compulsions. Obsessions are distressing, repetitive thoughts or images that the individual often realizes are senseless. Compulsions are repetitive behaviors that the person feels forced or compelled into doing, in order to relieve anxiety. One example would be the obsession of extreme cleanliness and fear of contamination, which may lead to the compulsion of having to wash one's hands hundreds of times a day. Another example may be the obsession that one's door is unlocked, which may lead to the constant checking and rechecking of doors.

Treatment overview
Mainstream treatment for anxiety consists of the prescription of anxiolytic agents and/or referral to a cognitive-behavioral therapist. There are indications that a combination of the two can be more effective than either one alone.

Prescription medication
The acute symptoms of anxiety are most often controlled with anxiolytic agents such as benzodiazepines. Diazepam (valium) was one of the first such drugs. Today there are a wide range of anti-anxiety agents that are based on benzodiazepines, although only two have been approved for panic attacks, Klonopin and Xanax. All benzodiazepines are physically addictive, and extended use should be carefully monitored by a physician, preferably a psychiatrist. It is very important that once placed on a regimen of regular benzodiazepine use, the user should not abruptly discontinue the medication.

Some of the SSRIs (selective serotonin reuptake inhibitors) have been used with varying degrees of success to treat patients with chronic anxiety, the best results seen with those who exhibit symptoms of clinical depression and non-specific anxiety or general anxiety disorder concurrently. Beta blockers are also sometimes used to treat the somatic symptoms associated with anxiety, especially the shakiness of "stage fright."

Many scientists believe that the benzodiazepines and other antianxiety drugs are greatly overprescribed and potentially addictive. See, for example, Fred Leavitt's The REAL Drug Abusers (Rowman & Littlefield, 2003). The addicitive nature of the benzodiazepine class became apparent in the mid 1960's when Valium (Diazepam), the first drug in the class to win FDA approval, resulted in thousands of people who quickly showed the classic symptoms of addiction when used for more than a week or two consistently.

The most addictive of the benzodiazepines appears to be Xanax due to its rapid onset and short half life in the blood stream. Xanax also has the dubious distinction of being the only benzodiazepine that often requires hospitalization for discontinuation as a precaution against dangerous and sometimes fatal seizures as part of the detoxification process. No other medications in this class have shown this fatal side effect, although abrupt discontinuation of virtually any benzodiazepine can result in cravings, stomach pains, cramps, increased anxiety, insomnia and other signs of withdrawal.

Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) is the most popular and effective form of psychotherapy used to treat anxiety. The goal of the cognitive-behavioral therapist is to decrease avoidance behaviors and help the patient develop coping skills. This may entail:


 * Challenging false or self-defeating beliefs.
 * Developing a positive self-talk skill.
 * Developing negative thought replacement.
 * Systematic desensitization, also called exposure (used for agoraphobia and OCD mainly).
 * Providing knowledge that will help the patient cope. (For example, someone who suffers from panic may be informed that fast, prolonged, heart palpitations are in themselves harmless).

Unlike prescription medication, the effectiveness of cognitive-behavioral therapy depends on various subjective factors, such as therapist competence. In addition to conventional therapy, there are at-home cognitive-behavioral programs sufferers can use as part of their treatment.

Other coping strategies
A variety of over the counter supplements and medications are also used for their alleged anti-anxiety properties, however there is little scientific evidence to back up these claims. Kava Kava is a popular herbal treatment; small doses either taken regularly through the day or when early symptoms are noticed by the patient. Valerian root is also reputed to have anti-anxiety and sedative properties, as are passion fruit, passion flower, St. John's wort, hops, and chamomile.

Popular nutritional supplements for dealing with anxiety include magnesium and B-complex vitamins.

Self help and relaxation techniques also play an important role in relieving anxiety symptoms. Self help includes:


 * Proper diet - This includes reduction in consumption of caffeine, sugar, and generally an improvement of eating habits. Caffeine reduction should be gradual. Some anxiety sufferers report considerable reductions in their anxiety just from taking these measures.
 * Exercise - Some exercise is thought to relieve stress. Anxiety sufferers should note that rapid heart palpitations during exercise can trigger a panic attack, so it is probably better to gradually develop an exercise routine while on a cognitive-behavioral program.
 * Laughing
 * Breathing techniques and proper breathing - A Diaphragmatic breathing technique is often recommended (as opposed to chest breathing).
 * Proper sleep.
 * Meditation
 * Relaxation techniques - A state of relaxation can be achieved with the help of relaxation tapes, Yoga or relaxation therapy.
 * Stress management.- This may entail changes in lifestyle and time management. There are a number of books specialized in stress management.
 * Panic attack coping strategies - Specific strategies for dealing with panic episodes have been proposed, such as slow abdominal breathing and use of reassuring self-talk.
 * Search for meaning and purpose - Some experts have indicated that residual generalized anxiety can be the result of a sort of "boredom" about existence. They recommend looking for an occupation the sufferer finds meaningful.
 * For people who feel anxious and don't know why, it is worthwhile to sort out whether the anxiety is over a particular circumstance or a more abstract existential worry.

Alcoholic drinks are probably the most widely used substance for the alleviation of anxiety. Anxiety sufferers are cautioned that alcohol is also a powerful depressant and has a plethora of dangerous and uncomfortable side effects in addition to being potentially addictive. Some evidence suggests that consuming alcohol to alleviate anxiety may be counter-productive, as it can lead to a higher or irregular heartbeat and lowering of blood sugar which can both add to the unpleasant symptoms of anxiety and panic.

Anxiety in palliative care
Some research has strongly suggested that treating anxiety in cancer patients improves their quality of life. The treatment generally consists of counselling, relaxation techniques or pharmacologically with benzodiazepines.

Anxiety and alternative medicine
A 2002 CDC survey (see table 3 on page 9) found that complementary and alternative methods were used to treat anxiety/depression by 4.5 percent of U.S. adults who used CAM.

Existential anxiety
Theologians like Paul Tillich and psychologists like Sigmund Freud have characterized anxiety as the reaction to what Tillich called, "The trauma of nonbeing." That is, the human comes to realize that there is a point at which they might cease to be (die), and their encounter with reality becomes characterized by anxiety. Religion, according to both Tillich and Freud, then becomes a carefully crafted coping mechanism in response to this anxiety since they redefine death as the end of only the corporal part of human personal existence, assuming an immortal soul. What then becomes of this soul and through what criteria is the cardinal difference of various religious faiths.

Philosophical ruminations are a part of this condition, and this is part of obsessive-compulsive disorder. They are typically about sex and religion or death.

According to Viktor Frankl, author of Man's Search for Meaning, when faced in extreme mortal dangers the very basic of all human wishes is to find a meaning of life to combat this "trauma of nonbeing" as death is near and to succumb to it (even by suicide) seems like a way out.

Test anxiety
Test anxiety is the uneasiness, apprehension, or nervousness felt by students who have a fear of failing an exam. Students suffering from test anxiety may experience any of the following: the association of grades with personal worth, embarrassment by a teacher, taking a class that is beyond their ability, fear of alienation from parents or friends, time pressures, or feeling a loss of control. Emotional, cognitive, behavioral, and physical components can all be present in test anxiety. Sweating, dizziness, headaches, racing heartbeats, nausea, fidgeting, and drumming on a desk are all common. An optimal level of arousal is necessary to best complete a task such as an exam; however, when the anxiety or level of arousal exceeds that optimum, it results in a decline in performance. Because test anxiety hinges on fear of negative evaluation, debate exists as to whether test anxiety is itself a unique anxiety disorder or whether it is a specific type of social phobia.