Anxiety Disorders

Christina Hunt

Introduction

Most people who suffer from a mental illness are suffering from an anxiety disorder. Anxiety disorders include the following diagnoses: generalized anxiety disorder, specific phobia, social phobia, agoraphobia, panic disorder, obsessive-compulsive disorder, post traumatic stress disorder, and separation anxiety disorder. This paper will examine all of these disorders with the exception of separation anxiety disorder, which is normally found in children.

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The word anxiety comes from the Latin word anxious, which means distress and agitation (Bourne, 1990, p. 2). People who experience an anxiety disorder know the feeling of being agitated and distressed beyond normal experience. The many disorders classified under the broad heading of anxiety disorders are distinct, but similar in that they all contain elements of debilitating fear and worry.

General anxiety disorder, referred to as GAD, is characterized by overwhelming worry and anxiety. Its sufferers are overly sensitive to relatively minor events and worry excessively about life situations and circumstances. The excessive worry will lead the individual to avoid the situation, person, or circumstance that evokes their fear (Wolman & Stricker, 1994, p. 48). There are five basic fears that a person with GAD experiences: (a) fear of losing control, (b) fear of not being able to cope, (c) fear of failure, (d) fear of rejection or abandonment, and/or (e) fear of death and disease (Bourne, 1990, p. 11).

Phobias are the most prevalent kind of anxiety disorder. People's accounts of phobias have been recorded throughout history (Wolman & Stricker, 1994, p. 161). Phobias are different from general fears in that they are unrealistic or out of proportion with reality (Bourne, 1990, p. 3). A person with a phobia might experience heart palpitations, dizziness, breathlessness, and feel completely paralyzed when exposed to the source of the phobia. Dr. Archibald Hart, a psychologist and former Dean of the Graduate School of Psychology at Fuller Theological Seminary, states that phobias are caused by either trauma or conditioning (1999, p. 181). The three categories of phobias are: specific, social, and agoraphobia. Specific phobias can range from fear of heights to fear of animals or objects. A social phobia occurs when a person is unable to function properly in a social setting because of a debilitating fear. Socially phobic individuals tend to focus their attention toward themselves when confronted with stressful social situations (Hofmann, Moscovitch, Kim, & Taylor, 2004). They then become self-critical and demonstrate unrealistic expectations of themselves. Agoraphobia is literally "a fear of the marketplace." A person suffering from agoraphobia will demonstrate an intense fear of places or situations from which they cannot easily escape. This fear is accompanied by panic attacks thirty to fifty percent of the time (Hallowell, 1997, p. 170).

When the human body responds to a perceived emergency, a panic attack may occur. The way the body reacts before, during and after a panic attack is intended to protect the person, not to harm them. Symptoms that may precede a panic attack include increased sensitivity to light, tight throat, tunnel or diminished vision, indigestion, missed heartbeats, nausea, burning sensation in the stomach, acute hearing and intolerance to noise, light-headedness and dizziness, cold flashes, hyperventilation, and/or localized burning sensations (Hart, 1999, p. 43). During a panic attack, the individual will experience similar symptoms, but these will be far more intense. A person with a panic disorder is intensely afraid of experiencing another panic attack (Sarason & Sarason, 2002, p. 212).

A diverse condition involving unwanted distressing thoughts and compulsive rituals is known as obsessive-compulsive disorder, or OCD. One or more general themes such as contamination, religion, symmetry or hoarding may predominate (Abramowitz, Franklin, Schwartz, & Furr, 2003). Individuals with OCD recognize that their obsessions and rituals are unreasonable or excessive. Most ritualistic activity relates directly to a person's obsessive thoughts. For example, a person may engage in a repetitive washing ritual to remove "contamination" (Steketee, 1993, p. 5). The onset of OCD normally occurs in late adolescence or early adulthood. Men and women are equally affected by this disorder (Sarason & Sarason, 2002, p. 224).

Post-traumatic stress disorder, referred to as PTSD, may occur after a person experiences a rape, violent crime, war, natural disaster, or other traumatic event that instills a sense of helplessness and overwhelming loss. Flashbacks, nightmares, or random associations of the event are symptomatic of PTSD (Hallowell, 1997, p. 94). Many individuals report feelings of irritability, restlessness, depression, and guilt. The symptoms of PTSD may occur immediately following the trauma, or they may not occur until months or years after the event (Sarason & Sarason, 2002, p. 229).

Differential Diagnosis Questions

Anxiety disorder symptoms may overlap with each other. In the initial therapy session, it is important to ask the right questions to determine a precise diagnosis. The first question should be, "When did the symptoms first start?" Panic disorder and GAD normally occur later in life, whereas OCD and PTSD normally occur before a person's middle twenties. Gender also plays a role. More women than men are diagnosed with panic disorder and phobias. Questions concerning depression and substance abuse should also be addressed. Depression is more common in panic disorder than in GAD (Sarason & Sarason, 2002, pp. 215-217). Appendix I provides suggestions to aid the therapist in asking differential diagnosis questions.

Possible Etiology Factors to Assess and Questions to Ask in Assessment

Anxiety disorders have many possible causes. Etiology factors addressed here do not apply to every client and case. The therapist should uncover biological factors that might contribute to the client's symptoms. Some anxiety disorders are caused by recent and short-term events that trigger symptoms, some are predisposing causes that occurred in birth or childhood and set up a person to develop anxiety at a later date, and some are maintaining causes that continue to produce symptoms throughout life (Bourne, 1990, p. 20).

A significant amount of research has been conducted on the brain and genetics in reference to their influence on a person diagnosed with an anxiety disorder. The evidence points to strong heredity correlations between family member diagnosed with GAD and OCD (Sarason & Sarason, 2002, p. 215). Childhood experiences may cause some anxiety disorders. Fifty percent of agoraphobic individuals experienced separation anxiety in childhood (Sarason & Sarason, 2002, p. 223). The social and family environment in which the child is raised may impact future vulnerability to anxiety disorders.

The cognitive model of the origin of phobias suggests that catastrophic thoughts such as, "I would die if I were stuck in a crowded elevator," justify the avoidance of the stimulus. Many cognitive therapists believe that as a result of phobic worry a deficit in a person's problem-solving skills occurs before and after an experience with the feared stimulus (Wolman & Stricker, 1994, pp. 168-169). If the client is gaining attention, sympathy, or any other form of positive or negative feedback, he or she may resist treatment because he or she does not want to change. The following questions should be answered during the initial session:

  • How long have you been experiencing these symptoms?
  • Are you taking any medications?
  • Does anyone in your family have an anxiety disorder?
  • Why are you seeking treatment now?
  • What are you hoping to accomplish through therapy?
  • Tell me about your expectations during the treatment process.
  • What efforts are you willing to make before, during, and after treatment?

Preferred Therapeutic Interventions of Treatment

Three psychological theories have produced successful treatment results when applied to clients suffering from anxiety disorders.These are the biological, cognitive, and behavioral approaches. There are many variations of these treatment approaches used in therapy.

The biological approach examines the physiological causes of a disorder. The body is a complicated and intricate design. All parts must work together in harmony and balance. People who experience panic attacks may have difficultly responding properly to stress (Hart, 1999, p. 55). The same is true of person suffering from general anxiety disorder. Positive thinking alone cannot correct the symptoms of GAD. It is a medical diagnosis that frequently requires anti-anxiety medication, such as Klonopin, to prevent the person's nervous system from overreacting to stress. The intense fear experienced by individuals with anxiety disorders cannot be fully explained when biological factors are excluded (Hallowell, 1997, pp. 10-15). Dr. Edmund Bourne, who specializes in the treatment of panic, phobias, and other anxiety disorders, is the director of the Anxiety Treatment Center in Campbell and Santa Rosa, California. His book, The Anxiety and Phobia Workbook, explains that the brain makes its own benzodiazepine-like substances, which are similar to tranquilizers. When a person's body does not produce enough of this substance, it may be responsible for a person having OCD or GAD. Individuals with OCD are prescribed medications such as clomipramine and fluoxetine to increase the amount of serotonin in the body (1990, pp. 30-31). The biological approach to treatment is normally accompanied by one of the other three approaches.

The cognitive approach encourages the therapist and client to collaboratively improve the client's thinking, feelings, and behavior (Wolman & Stricker, 1994, p. 87). A person may have had a childhood experience that increased anxiety sensitivity. This person will be at higher risk for developing panic attacks (Smits, Powers, Cho, & Telch, 2004). The cognitive restructuring approach aids the client to identify and challenge distorted thoughts and beliefs about the world, others, and themselves (Creamer & Forbes, 2004). Thought stopping and cognitive rehearsal are two additional cognitive approaches frequently used with cognitive restructuring. In thought stopping, the individual brings to mind an obsessive thought, and the therapist says "Stop." This process repeats until the client is able to internally stop the thought. In cognitive rehearsal, the client uses problem solving strategies in imagined anxiety producing situations (Sarason & Sarason, 2002, p. 237).

The behavioral perspective is based on the exposure approach to treatment. The client is "exposed" to whatever makes them feel worried or anxious. The therapist may induce the client to think about the anxiety-producing stimulus or situation, or the therapist may physically present an anxiety-producing medium to the client (Hallowell, 1997, pp.170-171). Prolonged exposure (PE) is used with many PTSD clients and has been the most widely assessed and strongly validated among all exposure therapies. It contains four elements: psychoeducation, breathing retraining, imaginal exposure, and in vivo exposure. It is administered through nine to twelve ninety-minute sessions once or twice a week (Cook, Schnurr, & Foa, 2004). The client confronts the feared stimulus and remains there until the anxiety diminishes (Creamer & Forbes, 2004). Modeling is another behavioral approach. It is normally used in combination with exposure therapies. In modeling, the client acquires behavioral skills and gains a sense of competence (Sarason & Sarason, 2002, p. 234).

Basic Treatment Recommendations and Likely Prognosis

Anxiety disorders are treatable. It is important for the therapist to treat each client individually. There is not one treatment that will "cure" every client. The therapist will probably experience resistance from the client to the treatment at some point. This is a healthy dynamic that will allow the person and therapist to work together through the issue. The therapist must keep in mind that his or her job is to give the client tools to work with. The client is ultimately in charge of his or her prognosis.

General anxiety disorders are treatable, although no single approach is successful in all cases. A combination of medication and cognitive or behavioral approaches will be more successful than the use of only one approach (Sarason & Sarason, 2002, pp. 211-212). The client must take ownership of his or her treatment in order to receive healing from GAD.

The prognosis for phobias and panic disorders is goodThe prognosis for phobias and panic disorders is good. The client must slow down his or her thinking, challenge mistaken beliefs he or she might have about a situation, person, themselves, or anything else in their world, and speak truth to his or her false belief (Hart, 1999, p. 112). Exposure therapies are commonly used for treating this disorder, and research suggests that they are very successful.

Obsessive-compulsive disorder remains a chronic condition, but it is highly treatable and not as disabling as it once was (Hallowell, 1997, p. 163). The most effective methods of treatment for patients with OCD are behavioral methods. Research confirms that the exposure and ritual prevention approach is the most effective treatment for OCD (Abramowitz, Foa, & Franklin, 2003). It is particularly effective for the more common forms of OCD, namely cleaning and checking. Antidepressant medications have been very helpful in relieving some symptoms of OCD, although most have side effects (Bourne, 1990, p. 353). Dr. Gail Steketee is endorsed and funded by the National Institute of Mental Health for her research on behavioral treatment of anxiety disorders. According to Steketee, a good prognosis for a person with OCD will depend on positive social functioning outside the home, positive family and marital factors, and early intervention and treatment (1993, pp.161-167).

Creamer and Forbes have observed that post-traumatic stress disorder is a chronic condition for at least half of all military personnel affected with it (2004). Complete recovery from PTSD is very rare. Combinations of treatment approaches have better outcomes than the use of one single approach (Sarason & Sarason, 2002, pp. 230-231). Individuals with PTSD respond well to treatments used in grief counseling. They should be encouraged to mourn the loss or losses in their life and seek forgiveness if the situation requires it (Hallowell, 1997, p. 95).

Many people are diagnosed with an anxiety disorder after a trauma or loss experience. In these cases the event should be memorialized through a ritual that allows the person to grieve the loss or trauma and then move forward (Hicks, 1993, pp. 186-187). This can be accomplished by having the person write a letter, make a large or small memorial, or commemorate the event in some other meaningful way.

References: Five Key Books

There are many valuable resources for professionals on the topic of anxiety disorders. Current research on the topic is finding many beneficial treatment approaches to administer in therapy. Any professional treating individuals with anxiety disorders should have these recommended resources in his or her library.

  • The Anxiety and Phobia Workbook by Edmund J. Bourne
  • Anxiety Disorders & Phobias: A Cognitive Perspective by A. Beck and G. Emery
  • The Anxiety Cure by Archibald Hart
  • Worry: Hope and Help by Dr. Edward Hallowell
  • Abnormal Psychology by Irwin G. Sarason and Barbara R. Sarason

Conclusion

As King David said in Psalms 139:14, "I praise you [God] because I am fearfully and wonderfully made." Every person is unique and special. All people have issues and problems that they face every day, and everyone responds to those challenges differently. When professional counselors have the privilege of treating someone and walking with them through their anxiety, it is essential for them to see the person as God sees them--a whole person who is loved. Therapists must always strive to view the person as a unit: body, mind, and spirit. All three areas must be addressed if an individual is to receive complete healing and wholeness.

QUESTIONS TO ASK IN TREATMENT

GAD
Phobias
Panic
DISORDER
OCD
PTSD

Do you experience overwhelming and debilitating fear?

YES
YES
YES
YES
Sometimes

Do you constantly worry about everything, even little things?

YES
NO
NO
YES
NO

Do you have nagging thoughts that tell you to do or not do certain things?

YES
NO
NO
YES
NO

Do you have certain habits (rituals) that take excessive amounts of time?

NO
NO
NO
YES
NO

Do you avoid situations that might cause anxiety in you?

YES
YES
YES
YES
Sometimes

Do you consider your behavior to be irrational and/or abnormal?

NO
YES
NO
YES
NO

Have you experienced a traumatic event in your life?

NO
Maybe
Maybe
Maybe
YES

Do you have flashbacks?

NO
NO
NO
NO
YES

Do you fear what might happen to you?

YES
YES
YES
NO
YES

Do you fear what you might do?

NO
NO
NO
YES
NO

Is there a family history of this disorder?

NO
NO
YES
Maybe
NO

Appendix/Bibliography

     Abramowitz, J. S., Foa, E. B., & Franklin, M. E. (2003). Exposure and ritual prevention for obsessive-compulsive disorder: effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71 (2), 394-398. Retrieved March 2, 2005, from PsycARTICLES database.

     Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology,71 (6), 0022-006X. Retrieved March 2, 2005, from PsycARTICLES database.

     Bourne, E. J. (1990). The anxiety and phobia workbook. Oakland, CA: New Harbinger Publications.

     Cook, J. M., Schnurr, P. P., & Foa, E. B. (2004). Bridging the gap between post traumatic stress disorder research and clinical practice: the example of exposure therapy. Psychotherapy: Theory, Research, Practice, Training, 41 (4), 0033-3204. Retrieved March 2, 2005, from PsycARTICLES database.

     Creamer, M. & Forbes, D. (2004). Treatment of post traumatic stress disorder in military and veteran populations. Psychotherapy: Theory, Research, Practice, Training, 41(4), 0033-3204. Retrieved March 2, 2005, from PsycARTICLES database.

     Hallowell, E. M. (1997). Worry: Hope and help for a commoncondition. New York, NY:Ballantine Books.

     Hart, A. D. (1999). The anxiety cure. Nashville, TN: Word Publishing.

     Hicks, R. (1993). Trauma: the pain that stays.Grand Rapids, MI: Fleming H. Revell.

     Hofmann, S. G., Mosocovitch, D. A., Kim, H. J., & Taylor, A. N. (2004). Changes in self-perception during treatment of social phobia. Journal of Consulting and Clinical Psychology, 72 (4), 0022-006X. Retrieved March 2, 2005, from PsycARTICLES database.

     Sarason, B. S., & Sarason, I. G.(2002). Abnormal Psychology: The problem of maladaptive behavior. Upper Saddle River, NJ: Prentice Hall.

     Smits, J. A., Powers, M. B., Cho, Y., & Telch, M. J. (2004). Mechanism of change in cognitive-behavioral treatment of panic disorder: evidence for the fear of fearmediational hypothesis. American Psychological Association, 72 (4). Retrieved March 2, 2005, from PsycARTICLESdatabase.

     Steketee, G. S. (1993). Treatment of obsessive compulsivedisorder. New York, NY:Guilford Press.

     Wolman, B. B., & Stricker, G. (Eds.). (1994). Anxiety and related disorders: A handbook. New York, NY: John Wiley & Sons.

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