Dr. MJ Bazos MD,
Generalized Anxiety Disorder
"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."
"I'd have terrible sleeping problems.
There were times I'd wake up wired in the morning or 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." Generalized anxiety
disorder (GAD) is much more than the normal anxiety people experience day to
day. It's chronic and exaggerated worry and tension, even though nothing seems
to provoke it. Having this disorder means always anticipating disaster, often
worrying excessively about health, money, family, or work. Sometimes, though,
the source of the worry is hard to pinpoint. Simply the thought of getting
through the day provokes anxiety. People
with GAD can't seem to shake their concerns, even though they usually realize
that their anxiety is more intense than the situation warrants. People with GAD
also seem unable to relax. They often have trouble falling or staying asleep.
Their worries are accompanied by physical symptoms, especially trembling,
twitching, muscle tension, headaches, irritability, sweating, or hot flashes.
They may feel lightheaded or out of breath. They may feel nauseated or have to
go to the bathroom frequently. Or they
might feel as though they have a lump in the throat.
Many individuals with GAD startle more
easily than other people. They tend to feel tired, have trouble concentrating,
and sometimes suffer depression, too.
Usually the impairment associated with
GAD is mild and people with the disorder don't feel too restricted in social
settings or on the job. Unlike many other anxiety disorders, people with GAD
don't characteristically avoid certain situations as a result of their disorder.
However, if severe, GAD can be very debilitating, making it difficult to carry
out even the most ordinary daily activities.
GAD comes on gradually and most often
hits people in childhood or adolescence, but can begin in adulthood, too. It's
more common in women than in men and often occurs in relatives of affected
persons. It's diagnosed when someone spends at least 6 months worried
excessively about a number of everyday problems.
In general, the symptoms of GAD seem
to diminish with age. Successful treatment may include a medication called
buspirone. Research into the effectiveness of other medications, such as
benzodiazepines and antidepressants, is ongoing. Also useful are
cognitive-behavioral therapy, relaxation techniques, and biofeedback to control
muscle tension. Panic Disorder
" It started 10 years ago. I was
sitting in a seminar in a hotel and this thing came out of the clear blue. I
felt like I was dying." "For me, a panic
attack is almost a violent experience. I feel like I'm going insane. It makes me
feel like I'm losing control in a very extreme way. My heart pounds really hard,
things seem unreal, and there's this very strong feeling of impending doom."
"In between attacks there is this dread
and anxiety that it's going to happen again. It can be very debilitating, trying
to escape those feelings of panic." People
with panic disorder have feelings of terror that strike suddenly and repeatedly
with no warning. They can't predict when an attack will occur, and many develop
intense anxiety between episodes, worrying when and where the next one will
strike. In between times there is a persistent, lingering worry that another
attack could come any minute. When a
panic attack strikes, most likely your heart pounds and you may feel sweaty,
weak, faint, or dizzy. Your hands may tingle or feel numb, and you might feel
flushed or chilled. You may have chest pain or smothering sensations, a sense of
unreality, or fear of impending doom or loss of control. You may genuinely
believe you're having a heart attack or stroke, losing your mind, or on the
verge of death. Attacks can occur any time, even during nondream sleep. While
most attacks average a couple of minutes, occasionally they can go on for up to
10 minutes. In rare cases, they may last an hour or more.
Panic disorder strikes between 3 and 6
million Americans, and is twice as common in women as in men. It can appear at
any age—in children or in the elderly—but most often it begins in
young adults. Not everyone who experiences panic attacks will develop panic
disorder—for example, many people have one attack but never have another.
For those who do have panic disorder, though, it's important to seek treatment.
Untreated, the disorder can become very disabling.
Panic disorder is often accompanied by
other conditions such as depression or alcoholism, and may spawn phobias, which
can develop in places or situations where panic attacks have occurred. For
example, if a panic attack strikes while you're riding an elevator, you may
develop a fear of elevators and perhaps start avoiding them.
Some people's lives become greatly
restricted—they avoid normal, everyday activities such as grocery
shopping, driving, or in some cases even leaving the house. Or, they may be able
to confront a feared situation only if accompanied by a spouse or other trusted
person. Basically, they avoid any situation they fear would make them feel
helpless if a panic attack occurs. When people's lives become so restricted by
the disorder, as happens in about one-third of all people with panic disorder,
the condition is called agoraphobia. A tendency toward panic disorder and
agoraphobia runs in families. Nevertheless, early treatment of panic disorder
can often stop the progression to agoraphobia.
Studies have shown that proper
treatment—a type of psychotherapy called cognitive-behavioral therapy,
medications, or possibly a combination of the two—helps 70 to 90% of
people with panic disorder. Significant improvement is usually seen within 6 to
8 weeks. Cognitive-behavioral
approaches teach patients how to view the panic situations differently and
demonstrate ways to reduce anxiety, using breathing exercises or techniques to
refocus attention, for example. Another technique used in cognitive-behavioral
therapy, called exposure therapy, can often help alleviate the phobias that may
result from panic disorder. In exposure therapy, people are very slowly exposed
to the fearful situation until they become desensitized to it.
Some people find the greatest relief
from panic disorder symptoms when they take certain prescription medications.
Such medications, like cognitive-behavioral therapy, can help to prevent panic
attacks or reduce their frequency and severity. Two types of medications that
have been shown to be safe and effective in the treatment of panic disorder are
antidepressants and benzodiazepines.
Phobias occur in several forms. A
specific phobia is a fear of a particular object or situation. Social phobia is
a fear of being painfully embarrassed in a social setting. And agoraphobia,
which often accompanies panic disorder, is a fear of being in any situation that
might provoke a panic attack, or from which escape might be difficult if one
occurred. Specific Phobias
"I'm scared to death of flying, and I
never do it anymore. It's an awful feeling when that airplane door closes and I
feel trapped. My heart pounds and I sweat bullets. If somebody starts talking to
me, I get very stiff and preoccupied. When the airplane starts to ascend, it
just reinforces that feeling that I can't get out. I picture myself losing
control, freaking out, climbing the walls, but of course I never do. I'm not
afraid of crashing or hitting turbulence. It's just that feeling of being
trapped. Whenever I've thought about changing jobs, I've had to think, "Would I
be under pressure to fly?" These days I only go places where I can drive or take
a train. My friends always point out that I couldn't get off a train traveling
at high speeds either, so why don't trains bother me? I just tell them it isn't
a rational fear." Many people
experience specific phobias, intense, irrational fears of certain things or
situations—dogs, closed-in places, heights, escalators, tunnels, highway
driving, water, flying, and injuries involving blood are a few of the more
common ones. Phobias aren't just extreme fear; they are irrational fear. You may
be able to ski the world's tallest mountains with ease but panic going above the
10th floor of an office building. Adults with phobias realize their fears are
irrational, but often facing, or even thinking about facing, the feared object
or situation brings on a panic attack or severe anxiety.
Specific phobias strike more than 1 in
10 people. No one knows just what causes them, though they seem to run in
families and are a little more prevalent in women. Phobias usually first appear
in adolescence or adulthood. They start suddenly and tend to be more persistent
than childhood phobias; only about 20% of adult phobias vanish on their own.
When children have specific phobias—for example, a fear of
animals—those fears usually disappear over time, though they may continue
into adulthood. No one knows why they hang on in some people and disappear in
others. If the object of the fear is
easy to avoid, people with phobias may not feel the need to seek treatment.
Sometimes, though, they may make important career or personal decisions to avoid
a phobic situation. When phobias
interfere with a person's life, treatment can help. Successful treatment usually
involves a kind of cognitive-behavioral therapy called desensitization or
exposure therapy, in which patients are gradually exposed to what frightens them
until the fear begins to fade. Three-fourths of patients benefit significantly
from this type of treatment. Relaxation and breathing exercises also help reduce
anxiety symptoms. There is currently
no proven drug treatment for specific phobias, but sometimes certain medications
may be prescribed to help reduce anxiety symptoms before someone faces a phobic
situation. Social Phobia
"I couldn't go on dates or to parties.
For a while, I couldn't even go to class. My sophomore year of college I had to
come home for a semester." "My fear would
happen in any social situation. I would be anxious before I even left the house,
and it would escalate as I got closer to class, a party, or whatever. I would
feel sick to 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
too embarrassed to stand off in a corner by myself, but I couldn't think of
anything to say to anybody. I felt so clumsy, I couldn't wait to get out."
Social phobia is an intense fear of
becoming humiliated in social situations, specifically of embarrassing yourself
in front of other people. It often runs in families and may be accompanied by
depression or alcoholism. Social phobia often begins around early adolescence or
even younger." If you suffer from
social phobia, you tend to think that other people are very competent in public
and that you are not. Small mistakes you make may seem to you much more
exaggerated than they really are. Blushing itself may seem painfully
embarrassing, and you feel as though all eyes are focused on you. You may be
afraid of being with people other than those closest to you. Or your fear may be
more specific, such as feeling anxious about giving a speech, talking to a boss
or other authority figure, or dating. The most common social phobia is a fear of
public speaking. Sometimes social phobia involves a general fear of social
situations such as parties. More rarely it may involve a fear of using a public
rest room, eating out, talking on the phone, or writing in the presence of other
people, such as when signing a check.
Although this disorder is often
thought of as shyness, the two are not the same. Shy people can be very uneasy
around others, but they don't experience the extreme anxiety in anticipating a
social situation, and they don't necessarily avoid circumstances that make them
feel self-conscious. In contrast, people with social phobia aren't necessarily
shy at all. They can be completely at ease with people most of the time, but
particular situations, such as walking down an aisle in public or making a
speech, can give them intense anxiety. Social phobia disrupts normal life,
interfering with career or social relationships. For example, a worker can turn
down a job promotion because he can't give public presentations. The dread of a
social event can begin weeks in advance, and symptoms can be quite debilitating.
People with social phobia are aware
that their feelings are irrational. Still, they experience a great deal of dread
before facing the feared situation, and they may go out of their way to avoid
it. Even if they manage to confront what they fear, they usually feel very
anxious beforehand and are intensely uncomfortable throughout. Afterwards, the
unpleasant feelings may linger, as they worry about how they may have been
judged or what others may have thought or observed about them.
About 80% of people who suffer from
social phobia find relief from their symptoms when treated with
cognitive-behavioral therapy or medications or a combination of the two. Therapy
may involve learning to view social events differently; being exposed to a
seemingly threatening social situation in such a way that it becomes easier to
face; and learning anxiety-reducing techniques, social skills, and relaxation
techniques. The medications that have
proven effective include antidepressants called MAO inhibitors. People with a
specific form of social phobia called performance phobia have been helped by
drugs called beta-blockers. For example, musicians or others with this anxiety
may be prescribed a beta-blocker for use on the day of a performance.
"I couldn't do anything without
rituals. They transcended every aspect of my life. Counting was big for me. When
I set my alarm at night, I had to set it to a number that wouldn't add up to a
"bad" number. If my sister was 33 and I was 24, I couldn't leave the TV on
Channel 33 or 24. 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. If I was writing a term paper, I couldn't
have a certain number of words on a line if it added up to a bad number. I was
always worried that if I didn't do something, my parents were going to die. Or I
would worry about harming my parents, which was completely irrational. I
couldn't wear anything that said Boston because my parents were from Boston. I
couldn't write the word "death" because I was worried that something bad would
happen." "Getting dressed in the
morning was tough because I had a routine, and if I deviated from that routine,
I'd have to get dressed again. I knew the rituals didn't make sense, but I
couldn't seem to overcome them until I had therapy."
Obsessive-compulsive disorder is
characterized by anxious thoughts or rituals you feel you can't control. If you
have OCD, as it's called, you may be plagued by persistent, unwelcome thoughts
or images, or by the urgent need to engage in certain rituals.
You may be obsessed with germs or dirt, so
you wash your hands over and over. You may be filled with doubt and feel the
need to check things repeatedly. You might be preoccupied by thoughts of
violence and fear that you will harm people close to you. You may spend long
periods of time touching things or counting; you may be preoccupied by order or
symmetry; you may have persistent thoughts of performing sexual acts that are
repugnant to you; or you may be troubled by thoughts that are against your
religious beliefs. The disturbing
thoughts or images are called obsessions, and the rituals that are performed to
try to prevent or dispel them are called compulsions. There is no pleasure in
carrying out the rituals you are drawn to, only temporary relief from the
discomfort caused by the obsession. A
lot of healthy people can identify with having some of the symptoms of OCD, such
as checking the stove several times before leaving the house. But the disorder
is diagnosed only when such activities consume at least an hour a day, are very
distressing, and interfere with daily life.
Most adults with this condition
recognize that what they're doing is senseless, but they can't stop it. Some
people, though, particularly children with OCD, may not realize that their
behavior is out of the ordinary. OCD
strikes men and women in approximately equal numbers and afflicts roughly 1 in
50 people. It can appear in childhood, adolescence, or adulthood, but on the
average it first shows up in the teens or early adulthood. A third of adults
with OCD experienced their first symptoms as children. The course of the disease
is variable—symptoms may come and go, they may ease over time, or they can
grow progressively worse. Evidence suggests that OCD might run in families.
Depression or other anxiety disorders
may accompany OCD. And some people with OCD have eating disorders. In addition,
they may avoid situations in which they might have to confront their obsessions.
Or they may try unsuccessfully to use alcohol or drugs to calm themselves. If
OCD grows severe enough, it can keep someone from holding down a job or from
carrying out normal responsibilities at home, but more often it doesn't develop
to those extremes. A combination of
the two treatments is often helpful for most patients. Some individuals respond
best to one therapy, some to another. Two medications that have been found
effective in treating OCD are clomipramine and fluoxetine. A number of others
are showing promise, however, and may soon be available.
specifically a type called exposure and response prevention, has also proven
useful for treating OCD. It involves exposing the person to whatever triggers
the problem and then helping him or her forego the usual ritual—for
instance, having the patient touch something dirty and then not wash his hands.
This therapy is often successful in patients who complete a behavioral therapy
program, though results have been less favorable in some people who have both
OCD and depression. Post-Traumatic
Stress Disorder "I was raped when I
was 25 years old. For a long time, I spoke about the rape on an intellectual
level, as though it was something that happened to someone else. I was very
aware that it had happened to me, but there just was no feeling. I kind of
skidded along for a while." "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 felt
like my entire head was moving a bit, shaking, but that wasn't so at all. I
would get very flushed or a very dry mouth and my breathing changed. I was held
in suspension. I wasn't aware of the cushion on the chair that I was sitting in
or that my arm was touching a piece of furniture. I was in a bubble, just kind
of floating. And it was scary. Having a flashback can wring you out. You're
really shaken." "The rape happened the
week before Christmas, and I feel like a werewolf around the anniversary date. I
can't believe the transformation into anxiety and fear."
Post-Traumatic Stress Disorder (PTSD)
is a debilitating condition that follows a terrifying event. Often, people with
PTSD have persistent frightening thoughts and memories of their ordeal and feel
emotionally numb, especially with people they were once close to. PTSD, once
referred to as shell shock or battle fatigue, was first brought to public
attention by war veterans, but it can result from any number of traumatic
incidents. These include kidnapping, serious accidents such as car or train
wrecks, natural disasters such as floods or earthquakes, violent attacks such as
a mugging, rape, or torture, or being held captive. The event that triggers it
may be something that threatened the person's life or the life of someone close
to him or her. Or it could be something witnessed, such as mass destruction
after a plane crash. Whatever the
source of the problem, some people with PTSD repeatedly relive the trauma in the
form of nightmares and disturbing recollections during the day. They may also
experience sleep problems, depression, feeling detached or numb, or being easily
startled. They may lose interest in things they used to enjoy and have trouble
feeling affectionate. They may feel irritable, more aggressive than before, or
even violent. Seeing things that remind them of the incident may be very
distressing, which could lead them to avoid certain places or situations that
bring back those memories. Anniversaries of the event are often very difficult.
PTSD can occur at any age, including
childhood. The disorder can be accompanied by depression, substance abuse, or
anxiety. Symptoms may be mild or severe—people may become easily irritated
or have violent outbursts. In severe cases they may have trouble working or
socializing. In general, the symptoms seem to be worse if the event that
triggered them was initiated by a person—such as a rape, as opposed to a
flood. Ordinary events can serve as
reminders of the trauma and trigger flashbacks or intrusive images. A flashback
may make the person lose touch with reality and reenact the event for a period
of seconds or hours or, very rarely, days. A person having a flashback, which
can come in the form of images, sounds, smells, or feelings, usually believes
that the traumatic event is happening all over again.
Not every traumatized person gets
full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the
symptoms last more than a month. In those who do have PTSD, symptoms usually
begin within 3 months of the trauma, and the course of the illness varies. Some
people recover within 6 months, others have symptoms that last much longer. In
some cases, the condition may be chronic. Occasionally, the illness doesn't show
up until years after the traumatic event.
Antidepressants and anxiety-reducing
medications can ease the symptoms of depression and sleep problems, and
psychotherapy, including cognitive-behavioral therapy, is an integral part of
treatment. Being exposed to a reminder of the trauma as part of
therapy—such as returning to the scene of a rape—sometimes helps.
And, support from family and friends can help speed recovery.
How to Get Help for Anxiety
Disorders If you, or someone you know,
has symptoms of anxiety, a visit to the family physician is usually the best
place to start. A physician can help you determine if the symptoms are due to an
anxiety disorder, some other medical condition, or both. Most often, the next
step to getting treatment for an anxiety disorder is referral to a mental health
professional. Among the professionals
who can help are psychiatrists, psychologists, social workers, and counselors.
However, it's best to look for a professional who has specialized training in
cognitive-behavioral or behavioral therapy and who is open to the use of
medications, should they be needed.
Psychologists, social workers, and
counselors sometimes work closely with a psychiatrist or other physician, who
will prescribe medications when they are required. For some people, group
therapy or self-help groups are a helpful part of treatment. Many people do best
with a combination of these therapies.
When you're looking for a health care
professional, it's important to inquire about what kinds of therapy he or she
generally uses or whether medications are available. It's important that you
feel comfortable with the therapy. If this is not the case, seek help elsewhere.
However, if you've been taking medication, it's important not to quit certain
drugs abruptly, but to taper them off under the supervision of your physician.
Be sure to ask your physician about how to stop a medication.
Remember, though, that when you find a
health care professional you're satisfied with, the two of you are working as a
team. Together you will be able to develop a plan to treat your anxiety disorder
that may involve medications, behavioral therapy, or cognitive-behavioral
therapy, as appropriate. Treatments for anxiety disorders, however, may not
start working instantly. Your doctor or therapist may ask you to follow a
specific treatment plan for several weeks to determine whether it's working.
Society for Traumatic Stress Studies: http://www.istss.org