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Psychiatric Descriptions


Anxiety is characterized by physical and psychological symptoms. The physical symptoms include rapid heartbeats, deep breathing, sweating, muscle tension, restlessness, and nausea. The psychological manifestation of anxiety is heightened awareness and apprehension. The brain mechanisms that mediate include many circuits and areas of the brain. The interplay of these diverse brain systems converges to dictate the basic sensations of anxiety.

In psychiatry, the focus of anxiety is the relation of the state with disease. Basically, in contrast to anxiety clearly provoked and amenable to control, pathological anxiety arises spontaneously or is produced out of proportion to what should be expected. It is important to note that physical and psychological sensations of anxiety are symptoms. Anxiety, in itself, is not a disease. Rather, it is a marker for a multitude of diseases - some of which exhibit anxiety as their predominant symptom. These disorders are "anxiety disorders," and some of the common anxiety disorders are presented below.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is used to describe patients with chronic anxiety - the term "chronic" in this sense denotes a presence of the symptoms for at least six months. Patients with GAD complain of persistent worry, irritability, and difficulty concentrating. The physical symptoms of GAD include restlessness, muscle tension, and insomnia. Usually, there is no specific stressor that can be attributed to causing the anxiety. The anxiety persists no matter what is happening in the person's life. This frustration leads patients to complain that they have no control and that they "just want to relax."

This type of chronic anxiety has been recognized for some time: Sigmund Freud termed it "anxiety neurosis." Current study of GAD reveals that about five percent of the population will develop GAD during its lifetime.

Study reveals that the onset of GAD is gradual. While patients usually begin to notice symptoms in adolescence or young adulthood, GAD can present earlier or later in life. Also, the course of GAD is long and about forty percent of patients report constant anxiety over five years, with the average duration ranging from six to ten years. Few studies have examined GAD patients over many years, but it is suspected that GAD can reoccur multiple times during an individual's life. Moreover, GAD has a predilection for females and there are about twice as many cases in women as there are in men.

Panic Disorder

The hallmark of panic disorder is the occurrence of unexpected panic attacks. A panic attack is a sudden, spontaneous episode of acute anxiety. Palpitations, increased heart rate, sweating, nausea, abdominal distress, trembling, dizziness, shortness of breath, and a feeling of choking are some of the physical symptoms noted in panic attacks. Psychological symptoms include fears of losing control or "going crazy," feelings of detachment, and even fears of dying. The symptoms of panic attacks develop quickly and usually reach a peak within ten minutes. To the sufferer, a panic attack may seem like an eternity - fortunately, these attacks rarely last more than thirty minutes.

Panic attacks have been described in literature for centuries and entered the medical sphere during the U.S. civil war. A physician named Jacob Da Costa described a condition that resembles the current description of panic attacks in Civil War soldiers. He termed it "irritable heart." While the name and specific criteria for these panic attacks have changed over time, the central theme of a sudden intense anxiety that is unprovoked has remained intact.

The study of panic attacks has revealed that they are quite common, and roughly seven percent of individuals will experience panic attacks during lifetime. Panic attacks tend to be recurrent and about one half of panic attack sufferers will have additional symptoms of concern towards additional attacks occurring in the future, worries about the implications of the attack, and changes in behavior related to the attacks. If an individual has these additional symptoms, then he or she subsequently meets the criteria for the illness known as panic disorder.

Panic disorder may further be sub-classified by using the modifying term "with agoraphobia" or "without agoraphobia." Agoraphobia is derived from the Greek word ageirein (meaning "place of assembly," commonly a marketplace) and phobos (meaning "fear.") Agoraphobia, in the medical sense, is a term used to describe the development of anxiety in places or situations from which one might have a perceived difficulty in escaping during the attack, and consequently feel embarrassed. Patients with agoraphobia will therefore avoid public places, and even traveling, in an effort to quell this anxiety. About one half of patients suffering from panic disorder have agoraphobia.

The course of panic disorder is of recurrent panic attacks followed by periods of remission. While panic attacks usually present in adolescence and young adulthood, they may present at any age. As a person with panic disorder ages, the panic attacks become less intense and less frequent. Studies also show that panic disorder is more common in females.

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) is a disorder in which anxiety is just one symptom of a constellation of findings that arises after exposure to a traumatic event or series of traumatic events. Simply, there are three basic clusters of symptoms.

The first cluster involves reexperiencing the traumatic event. An individual may recall (commonly described as "relive") the traumatic event through nightmares or "flashbacks." Flashbacks are vivid memories that are unwanted and usually provoked by a stimulus. For example, the smell of cedar may initiate the reliving of a rape of an individual that occurred in a closet.

The second cluster of symptoms pertains to avoiding stimuli that are associated with the trauma (commonly referred to as "avoidance"). Individuals will avoid people, places, situations, and activities that may trigger recall of the traumatic event. This may include the attempt to avoid any thoughts or feelings associated with the trauma. Following the previous example of a rape occurring in a closet, the victim of such horror may take extreme measures to avoid entering or even coming close to the closet in which the rape took place.

The last cluster of symptoms of PTSD is characterized by an overall increased arousal and anxiety that was not present before experiencing the traumatic event. Individuals may have an exaggerated startle response (be easily surprised), become increasingly vigilant (constantly watching and checking for danger), experience difficulty sleeping and concentrating, and suffer from irritability. Following once more the aforementioned example, the rape victim might live many years of his or her life with an unusually high amount of anxiety and terror.

The phenomenon of PTSD has been recognized for centuries. Boccacio's The Decameron describes the Florentine people during the Black Plague, relating examples of citizens' various reactions to the traumatic fear and loss of life experienced. The concept was revisited more carefully during World War I, during which the term "shell shock" came into the medical lexicon to describe the reaction of soldiers who continued to relive combat months after battle. More recently, studies of concentration camp survivors, war veterans, and survivors of natural disasters and accidents have shed more light on the nature of PTSD.

Studies of trauma reveal that it is a common occurrence and that around two thirds of the population will experience some form of trauma ranging from witnessing a traumatic event to rape and combat exposure in war. While everyone who is exposed to a severe traumatic event, such as rape and torture, initially develop symptoms that mimic PTSD, not all of these people develop the illness. Unfortunately however, PTSD is a common disorder, and from five to ten percent of the general population will develop PTSD during their lifetime. Once PSTD has set in, about sixty percent of the cases will resolve within months. For the population that continues to have symptoms, the duration and intensity of symptoms vary, though the course tends to be chronic without treatment.

Which population of trauma victims will develop PTSD is not yet completely understood. Several ideas about this point, however, do exist. First, the type of trauma is an important factor in developing PTSD. Events that involve interpersonal victimization, that is, trauma caused by others, such as rape and torture, have higher rates of PTSD than lower magnitude events such as natural disasters or life-threatening illnesses. Second, a history of prior exposure to trauma increases the risk for PTSD. Third, there is evidence for specific biological factors that predispose an individual to developing PTSD.

Social Phobia

Social phobia is an irrational fear of social situations in which the individual anticipates that he or she will act in an embarrassing or humiliating way. Exposure to the feared situation produces intense anxiety, and the patient will go to great means to avoid the feared social activity. The anxiety of social phobia resembles fear, and patients commonly have physical symptoms of palpitations, trembling, sweating, muscle tension, nausea, blushing, dry throat, and headache. The most frequent social situations feared in the social phobic patient are conversing in small social groups, meeting or speaking to new people or strangers, and of eating in public places.

Social phobia is different from shyness and that typical transient discomfort we have all at some time in our lives experienced in social places. The intensity of anxiety and discomfort is much higher in social phobia than in shyness. Furthermore, shy people tend to be shy in many situations, whereas the social phobic patient will only have anxiety towards the feared, specific social activity or situation. Moreover, in contrast to shyness, the anticipatory anxiety in social phobia may precede a social event by days or even weeks. Social phobic patients will go to great pains to avoid a feared social situation. For example, such a patient may constantly cancel a dinner appointment to avoid the possibility of embarrassment and humiliation.

Social phobia is the most common anxiety disorder and about ten to fifteen percent of the population will develop it during life. Females are twice as susceptible to social phobia and the reason for this is unknown. Studies of the natural course of social phobia reveal that symptoms usually begin in adolescence and tend to follow a chronic unremitting course. It is not known why people develop social phobia. However, there may be a genetic component as the disorder runs in families.

Specific Phobia

Like the association between anxiety and social situations in social phobia, specific phobias are marked by an irrational fear triggered by a specific object or situation. An individual with a specific phobia will avoid the trigger, and usually the individual is upset that he or she has this fear. Interestingly, a small number of objects and situations account for the majority of specific phobias. Some of the most common phobias, in decreasing order of prevalence, are animals, height, blood, close spaces, flying, water, being alone, and storms. The symptoms of specific phobia are intense anxiety and apprehension concerning the phobic object and situation.

Specific phobias are common - they are the second most common anxiety disorder. About ten percent of the population will meet criteria for a specific phobia during its lifetime. Like social phobia, specific phobias are more common in females. Specific phobias usually arise in childhood and adolescence. In some cases the phobia will resolve on its own; however, if the phobia continues into adulthood, the course tends to be chronic.

The exact reasons that individuals develop specific phobias are unknown. However, it has been hypothesized that there may be an evolutionary predisposition to fear certain objects or situations. For example, snakes may have been a real danger to our ancestors and those who avoided snakes were able to survive and reproduce. Thus we may have inherited a prepared fear response to snakes that enabled our ancestors to survive. This, of course, serves no present value to an urbanite, but could explain why only a small number of objects and situations account for the majority of specific phobias. Another hypothesis is that traumatic events or a series of traumatic events trigger specific phobias. For example, a snake may bite an individual on a camping trip. From then on, the individual may develop phobic symptoms when visiting the snake exhibit at the zoo or seeing snakes on television or magazines.

Although, specific phobias are a common occurrence, only about twenty percent of sufferers will seek treatment. This may be explained by the possibility that sometimes the object or situation of the phobia is easy to avoid, and hence does not require medical evaluation and intervention. For example, snakes are uncommon in urban settings, so a businessman working in a city and living in a nearby suburb might never have to come into contact with a snake. However, the fear of flying in an international businessman would be impossible to avoid and would interfere greatly in his life.