What Is Anxiety?

The dictionary definitions of anxiety include "a painful or apprehensive uneasiness of mind usually over an anticipated or impending ill" and a "fearful concern or interest". When we speak clinically of excess anxiety or anxiety disorders dictionary definitions are helpful but inadequate. Anxiety becomes a problem when the anxious, nervous, worried or fearful feelings begin to interfere with everyday life to a frequent and troubling degree. Some anxiety can be beneficial such as that which motivates us to study for a test or to practice the speech we have to give soon. Anxiety can be understandable and not excessive such as that which follows news of a tornado watch in your area or what a soldier often feels just before going into battle; as long as it doesn't interfere with preparation.

What surprises many people is that anxiety disorders are the most common psychiatric disorder ! The percentage of people who will have, at some time, Panic disorder is 1% of the population, Generalized Anxiety is 5%, a Specific Phobia is 11%, Agoraphobia is 5%, Social Phobia is 2.7%, Obsessive-Compulsive disorder is 2%, and Post Traumatic Stress Disorder is about 5%. School Phobia and Separation Anxiety Disorder are also often seen in youth. There is substantial overlap between these anxiety conditions. Anxiety Disorders are far more frequent than Schizophrenia or Bipolar Disorder (Manic-Depression) and even exceed the frequency of the various types of depression or alcoholism. Anxiety problems are even more common than Attention Deficit Hyperactivity Disorder and Learning Disorders in kids and Alzheimer's Disease in adults.

Although anxiety disorders can be severely disabling I am often impressed at how hard people work to overcome them and how successful they are in at least some areas of their lives even before seeking treatment. Anxiety problems, within limits, can even be helpful in some ways. Anxiety often helps us to prepare, to plan ahead, to care, to do what is right , and to make sure we have been thorough. Wouldn't you want the neurosurgeon operating on your brain (or lawyer handling your case, or accountant doing your taxes, or mechanic repairing your car) to be just a bit compulsive?

It is common for me to hear a patient tell me they didn't realize they had been so anxious until those symptoms were diminished by the medication we had used to treat what had been seen as only depression. They may notice less need to control things so much, more ability to not sweat the little things, more ability to try new things they have always wanted to do but were too nervous about. Their prior oversensitivity and over-reactivity may be lessened, resulting in less irritability and better temper control. Social interactions may be a bit easier or more enjoyable or there may be decreased discomfort in intimacy. Changing habits which may have been compulsive or letting go of obsessive thoughts seem easier. Sensitivity to certain textures, certain clothes, or sounds may be less. All of these traits are, in my view, included in the broader anxiety symptom spectrum.

Anxiety disorders may be complicated by other conditions such as depression or alcohol or other substance abuse. Anxiety problems, or vulnerability to them, often runs in families. Both the symptoms of anxiety and depression so often occur together in one person at varying times in their lives and overlap in family histories that I often see them as two sides of the same biologic coin. Even several of the most commonly effective medication and psychotherapy treatments are essentially the same.

Anxiety is too broad a topic to do justice in a newsletter alone, so I will address only some highlights of the diagnostic categories listed and described in DSM-IV. This issue will cover Generalized Anxiety Disorder, Panic Disorder, and the Phobias. Obsessive Compulsive Disorder will be covered in the next issue. Post Traumatic Stress Disorder will be discussed two issues from now.

Generalized Anxiety Disorder is best understood as excessive feelings of worry, nervousness, anxiety, and/or fear that interfere more days than not, causing significant distress or impairment in functioning in social relationships, school or work, or other areas of life. The focus of this anxiety may be unclear or float from one worry to another from time to time, or (most often) involve several areas of life along with a general uneasiness. This general anxiety may also include panic symptoms or unreasonable fears about important life tasks such as school or relationships. GAD frequently responds to medications such as the SSRI's (Prozac, Zoloft, Paxil, Luvox, Anafranil), Buspar, Serzone, Effexor or Remeron. GAD also is often well treated by psychotherapy using techniques of cognitive behavioral therapy and relation training.

Panic Disorder consists of recurrent "anxiety attacks" or "hyperventilation" episodes which build up over 5 to 10 minutes and last under an hour but are terrifying, although not inherently dangerous. Panic attacks are often marked by varying numbers of symptoms which may include shortness of breath, skipped heart beats, headache, nausea, tingling or numbness in fingers, toes, or lips, sweating, shaking, dizziness, feeling unreal or not like one's self, fear of dying, etc. It is difficult to overstate the fear or discomfort a panic attack causes. Persons suffering their first panic attack frequently go to emergency rooms or seek quick medical evaluation for what they fear is a dangerous disease. Fortunately, many such episodes are actually panic attacks which can usually be treated effectively and often recurrence can be prevented or lessened. Benzodiazepines (Ativan, Klonopin, Xanax, etc.) are very effective at stopping panic at the moment it builds up while SSRI's, and several other antidepressants are often very good at preventing them, lessening their intensity, or reducing their frequency. Psychotherapy is aimed at educating about panic disorder, lessening the symptoms, and especially preventing or overcoming the too often associated social avoidance, school refusal, and even agoraphobia (fear of leaving home) that may accompany severe or chronic or untreated panic attacks. Panic attacks may occur as part of other anxiety disorders.

Phobias include Social Phobia, Agoraphobia, and Specific Phobias.

Social Phobia is a marked and persistent fear of one or more social or performance situations in which the person feels overly exposed or likely to be embarrassed in front of other persons. This typically involves public settings such as malls, restaurants, performing, school, test taking, etc. If compelled to carry on the person feels exquisitely uncomfortable (anxious) and may have or fear a panic attack. In Agoraphobia this anxiety is broadened to frequently include multiple settings such that the person feels trapped in their home or other such refuge. Specific Phobias typically revolve around or are limited to one of the following: a particular animal type such as dogs, bugs, bees; a type of natural environment such as storms, heights, water; seeing an injury, blood, or injections; certain situations such as airplanes, elevators, or enclosed spaces; or "other" such as fear of choking, costumed characters, or acquiring infections. School Phobia or Refusal is not really a specific phobia and it is different from truancy or simply fear of being bullied etc. The anxiety is intense, focused on avoiding anxiety about school but in a broad way. It is often accompanied by stomach, bowel, headache or other vague health complaints and a desire to stay home -- not a desire to go out and play or see friends. School phobia may first show itself at preschool, or kindergarten, or first grade as a Separation Anxiety marked by trouble leaving the parent(s) or other "safe" setting. The child may be anxious about his or her ability to be OK without the parent or even about the parent's ability to be OK without the child. It is not unusual for separation anxiety or school phobia to show up again at around age 10 to 12 or even later such as starting middle school, high school, college, or a new job. Treatment of School Phobia can be an emergency due to its possibly disastrous effect on learning and socialization. School Phobia can be very hard on the youth and family as all parties struggle with how to understand and deal with this troubling condition. Treatment typically is based upon doing everything possible to ensure as much school attendance and participation as possible, as quickly as possible. Balancing this with the symptoms of the child can be an art and must be individualized. Psychotherapy for the child and the parents is often advised, along with specific guidance to each and to the school staff. Medication may include an SSRI as a cornerstone of the treatment. Since SSRI's may take a few weeks to work well, it can be quite helpful to add a Benzodiazepine to help with anxiety caused sleep disruption and or to make it substantially easier for the child to get out the door and into school. As with other anxiety disorders, School Phobia may be one component of a broader vulnerability to anxiety.

Most Tucson area schools now use the "Stanford 9" tests yearly to assess student achievements as a group and individually. You should receive your child's scores directly. Tucson wide scores for 4th, 7th and 10th grade, by school and district, are published in the paper yearly. Before I summarize the scores we should remember that a lot of factors may influence an individual child's or the total school's scores so that these scores should not be assumed to be an accurate or complete reflection of school quality. School quality is influenced by many factors beyond the obvious importance of the school's facilities, teachers, and administration. Other factors include the effort and brightness of the students, parental involvement, class size, range of classes available, discipline policy and safety, values taught and modeled, whether academic achievement is valued by peers, expectations for achievement at all levels, etc. These tests were all done in spring 1998. Most private and charter schools either do not take the tests or do not report them.

Colleagues at the Tucson Division of the Casey Family Program have searched the literature on self sufficiency development. One of their key findings is the following list of what people, especially youth, can do to keep their jobs. Failure to measure up in these areas are the main reasons youth lose their jobs. Think of these when you evaluate performance from an employer's perspective and teach these strengths to your teens.