Etiology and Treatment of Anxiety Disorders
Stress, worry and anxiety are a part of nearly everyone’s life and may be a way of anticipating possibly dangerous situations. However, when symptoms become severe or chronic enough to affect day-to-day living, an anxiety disorder may be diagnosed.
Anxiety disorders are the most prevalent disorders within the general population. Anxiety disorder, as outlined by the DSM-IV-TR (2000) consists of symptoms of muscle tension, shortness of breath, heart palpitations, stomach problems, confusion, fear, poor memory and difficulty with concentration, causing disturbances in occupational and social functioning, as well as difficulty in falling or staying asleep.
The DSM-IV-TR categorizes anxiety disorders as follows:
- generalized anxiety disorder (GAD)
- panic disorder with and without agoraphobia
- specific phobia (ie: heights, snakes, blood, etc.)
- social anxiety disorder (also known as social phobia)
- obsessive-compulsive disorder (OCD)
- posttraumatic stress disorder (PTSD)
When diagnosing an anxiety disorder, stimulant use (amphetamine, cocaine), excessive caffeine use, hyperthyroidism and withdrawal from alcohol, barbiturates and tranquilizers must be ruled out. Symptoms of other conditions, such as mania or hypomania, can mimic symptoms of anxiety (rapid heart beat, irritability, sweating, shaking, shortness of breath, chest pain, abdominal problems, dizziness, etc.) (APA, 2000) and must also be ruled out.
Screens such as the Beck Anxiety Inventory, the Hamilton Anxiety Rating Scale, the Social Phobia Inventory, the Generalized Anxiety Disorder Scale and the Yale-Brown Obsessive Compulsive Scale can be used to determine the type of anxiety as well as the severity of symptoms (Balon, 2007).
Anxiety is a natural human response that is closely related to fear. Unlike modern psychotherapists, Freud did not clearly differentiate between anxiety and fear, classifying both anxiety and fear as “angst”, the German word for both fear and anxiety (Craig, Brown & Baum, 2000). Fear is related to an identifiable external stimulus, such as an approaching hurricane or wild animal; whereas anxiety is linked with a repressed unconscious emotion and not an actual threat, such as anxiety about an unresolved conflict (Craig, et al., 2000).
Anxiety and fear are necessary warning adaptations that are a natural response in humans, alerting the individual to possible dangers. According to LeDoux (1998), the amygdala, our old reptilian brain, is the “heart and soul of the fear system”. The amygdala not only controls our survival responses, but responds in an automatic, immediate way, overriding our new brain, the prefrontal cortex, which is rational and analytical (Griffin & Tyrell, 2006). Thus, evolutionarily intended, automatic responses to threatening situations elicit the body’s fight-or-flight response; the hippocampus then encodes these threatening situations into the individual’s memories creating an anxiety response (LeDoux, 1998).
Because anxiety is rooted in a necessary cautionary adaptation and natural response in humans, treatment with medication is not always successful. Current medications for the treatment of anxiety disorders include benzodiazepines, such as Xanax and Valium, which offer a short-term reduction of symptoms. However, benzodiazepines are often over-prescribed and can lead to dependency problems for many individuals (Lemma, 2010). Treating anxiety with selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Luvox, Lexapro and Celexa, has been shown to be effective for the treatment of social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder. However, improvement is typically not noted for three to four weeks, with some individuals not responding to treatment for nearly twelve weeks, if at all (Roy-Byrne, Craske & Stein, 2005).
Cognitive behavioral therapy (CBT) is an evidence-based treatment modality that has received compelling research confirmation as an efficacious approach in the treatment of anxiety disorders (APA, 2006). CBT focuses on the premise that our behavior and emotions are unduly influenced by our constant stream of thoughts and by how we choose to view situations. According to CBT, our schemas, or basic beliefs, are developed very early in life and consist of very basic units of thinking that are developed through personal experiences with the world. Therefore, having negative or maladaptive schema or belief systems can greatly affect how we view the world and how we react to it. In addition, our automatic thoughts, which can be distorted, accurate, or distorted and accurate but dysfunctional, provide a constant stream of information that can cause anxiety and other types of emotional distress. Cognitive behavioral therapy attempts to help the individual identify the illogical beliefs and irrational thoughts that cause anxiety and endeavors to replace these cognitive distortions with healthier more adaptive methods of coping, or cognitive restructuring.
The cognitive therapist takes on an active, guiding role in the therapy process. Together with the client, treatment goals are formulated to identify and correct dysfunctional thought patterns. A variety of flexible techniques, which may include Socratic questioning, activity scheduling, exposure therapy and assertiveness training, may be used to reach the client’s goals. Homework assignments, which are considered to be of paramount importance in the cognitive therapy approach, not only ensures continuity between sessions, but can integrate anxiety reducing skills such as deep breathing techniques, calming self-talk, meditation, and progressive muscle relaxation into daily routines. Additionally, the CBT technique of exposure to the feared stimulus gradually desensitizes the individual to the fear and allows the person to successfully face their fear. By repeatedly being exposed to one’s fear, the individual learns to manage the difficult thoughts and anxious feelings associated with the stimulus, leading to an eventual reduction of symptoms (Griffin & Tyrell, 2006).
It is common that individuals with an anxiety disorder may also self-medicate with alcohol, drugs or food to manage their symptoms and it is estimated that 35.6% of individuals with an undiagnosed anxiety disorder self-medicate (Brady, Tolliver & Verduin, 2007). Alcohol is the most commonly used substance used to self-medicate for anxiety. Because alcohol depresses the central nervous system, it acts as a sedative and produces a calming effect, thereby reducing symptoms of anxiety. However, during the alcohol withdrawal phase, symptoms of anxiety are experienced, thereby creating a vicious cycle, in which the severity of both the anxiety disorder and problem drinking may begin to increase (Brady, Tolliver & Verduin, 2007).
It is also recommended that individuals with an anxiety disorder reduce or eliminate their caffeine consumption as excessive caffeine can contribute to symptoms of anxiety by activating the fight-or-flight response. Caffeine stimulates the central nervous system by blocking adenosine, releasing adrenaline and increasing the heart rate (Hoflander, 2011).
While it is important to recognize that anxiety is a natural human survival response, it is also imperative to know that anxiety can become a disorder when symptoms become uncontrollable and excessive and need no external stimulus. Affecting approximately forty million individuals over eighteen, anxiety disorders are the most prevalent mental illness in the United States (ADAA, 2012) and although anxiety disorders are decidedly treatable, only approximately one-third of individuals with an anxiety disorder obtain treatment, resulting in an economic burden in excess of $42 billion per year (ADAA, 2012).
As counselors working in private practice at GroundWork Counseling in the Orlando area, we have found that anxiety is the most common reason for women who seek therapy services. This is not surprising, as the Anxiety and Depression Association of America (ADAA, 2012) states that a woman between the ages of 15 and 50 is twice as likely as a man to suffer from an anxiety disorder. Additionally, research has found that the flight-or-fight response is activated more quickly in women than in men and stays activated longer due to the effects of the hormones progesterone and estrogen. In addition to utilizing CBT methods with our female clients, we typically include holistic life-style and self-care recommendations that include learning meditation and relaxation techniques, beginning a daily exercise program, limiting caffeine consumption and eating a healthful, well-balanced diet. Simply teaching our clients to close their eyes and take deep, slow breaths for a few minutes can make a big difference in reducing symptoms of anxiety.
Interestingly, children with anxiety also comprise a significant portion of the young clients treated by GroundWork Counseling’s child therapist. Whereas some childhood anxiety is expected and normal throughout various stages of development and can include separation anxiety, fear of the dark, fear of strangers or fear of animals, and so on, some children’s anxiety can reach a level where it interferes with social, family and academic functioning. Children exhibiting severe childhood anxiety can and should be treated to prevent future difficulties. GroundWork Counseling integrates CBT methods that challenge anxious thinking and teach problem solving skills along with play therapy, expressive art therapy and sand tray therapy approaches. Innovative child therapy techniques can help children to become aware of and learn to express their feelings so they may learn to manage anxiety in a developmentally appropriate way.
When anxieties are severe enough to interfere with an adult or child’s every day functioning, it may be appropriate to consider treatment from a qualified mental health professional. Treatment that incorporates cognitive behavioral therapy, which focuses on understanding and changing thought maladaptive thought patterns, is a well-established treatment for anxiety disorders that has been found to be highly effective; evidence based research has found that this may be the best approach in the treatment of many anxiety disorders.
References:
Presidential Task Force on Evidence-Based Practice. (2006).
APA: Evidence-based practice in psychology. American Psychologist, 61, 271-285.
Balon, R. (2007) Rating scales for anxiety/anxiety disorders. Current Psychiatry Reports. 2007 Aug;9(4):271-7. PubMed.
Brady, K.T., Tolliver, B.K. & Verduin, M.L. (2007) Alcohol Use and Anxiety: Diagnostic and Management Issues. American Journal of Psychiatry 2007;164:217-221.
Craig, K.J., Brown, K.J., & Baum, A. (2000) Environmental Factors in the Etiology of Anxiety. Archives of General Psychiatry. PubMed.
Griffin, J. & Tyrell, I. (2006) How to Master Anxiety: All You Need to Know to Overcome Stress, Panic Attacks, Trauma, Phobias, Obsessions and More. United Kingdom: HG Publishing
Hoflander, J. (2011). A Red Bull instead of a cigarette: Should the FDA regulate energy drinks? Valparaiso University Law Review, 45(2), 689-740.
LeDoux J. (1998) Fear and the brain: where have we been, and where are we going? Biological Psychiatry, 1998; 44(12): 1229-38.
Roy-Byrne P, Craske M. & Stein M, (2005) A randomized effectiveness trial of cognitive bebehavioral therapy and medication for primary care panic disorder. Archives of General Psychiatry. 2005, 62: 290-298.
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