When Anxiety is Overwhelming

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Most of us experience anxiety and fear at times. It's a natural emotional, a physical response to stress, and a normal part of life. But for many people, anxiety is a chronic intruder, causing extreme worry and tension, even when there is little or nothing to provoke such strong feelings. It can be so persistent and overwhelming that it interferes with daily activities. Someone who feels excessive anxiety about everyday problems may have generalized anxiety disorder (GAD).

Because anxiety is such a common emotion, GAD can go unrecognized. But it's very real, affecting about 4 million adults in the United States--two-thirds of whom are women.

GAD is one of several conditions known collectively as anxiety disorders (see box, left). Although treatment is available, less than half of the 23 million men and women who have some form of anxiety disorder (including GAD) actually receive help. Because their symptoms often resemble those of medical conditions such as heart attacks, strokes, and neurological problems, people with anxiety disorders make frequent visits to doctors' offices and emergency rooms. According to the Anxiety Disorders Association of America, these conditions cost more than $42 billion a year in the US, when both direct healthcare costs and lost productivity are considered.

RECOGNIZING GAD
When an individual has GAD, every aspect of her worry--its intensity, duration, and frequency--is disproportionate, regardless of whether she's focused on weighty matters such as work, finances, family, or health, or on more mundane concerns, such as household chores or keeping appointments. Even when people recognize that their concern is exaggerated, they can't extricate themselves from the rut of worry.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a diagnosis of GAD requires that an individual's worry and anxiety be accompanied by three or more of the following symptoms, on more days than not, for six months:

restlessness or feeling keyed up or on edge
being easily fatigued
trouble concentrating or mind going blank
irritability
muscle tension
sleep disturbance
Very often, GAD co-exists with other psychiatric conditions, especially depression and those involving anxiety. Symptoms can start in childhood and recur periodically throughout life. Stress aggravates it.

GAD can be difficult to diagnose because it develops slowly and lacks the dramatic symptoms, such as panic or social isolation, that characterize other anxiety disorders. Also, many medical conditions and drugs cause anxiety-like symptoms (to learn more, please visit our Web site at health.harvard.edu/women). A physical examination and medical history are essential in order to rule out these conditions.

WHAT CAUSES GAD?
Some research shows that the prevalence of GAD in adult women varies with age and ethnic group. For example, the highest rates are found in African-American women before age 30 and in Hispanic women at ages 45-64. The prevalence among Caucasian women remains fairly constant until around age 65, when it drops (Psych Clinics N Amer, 2001, Vol. 24, No.1, pp. 165-78).

Most people with an anxiety disorder seem more vulnerable, biologically, to stress and consequently more sensitive to environmental stimuli. Scientists describe GAD as an abnormal response to stressful stimuli that involves chemical messengers in the brain, particularly norepinephrine, serotonin, and gamma-aminobutyric acid (GABA). The cause of GAD is not fully understood, but experts believe it's a combination of biological and environmental factors.

Brain imaging and neurochemistry are helping scientists identify the areas of the brain responsible for our reactions to anxiety and fear. Fear automatically triggers a series of physical "fight or flight" responses. The heart pumps faster; blood rushes to the muscles; and blood sugar rises. At the same time, information relayed to the cerebral cortex, the cognitive part of the brain, tries to make sense of what's causing the fear. Our cognitive and physical responses are thought to be coordinated by the amygdala, an almond-shaped structure deep within the brain. The hippocampus, another brain structure, helps to turn these experiences into memories. Brain scans have detected abnormalities in the amygdalas of people with several anxiety disorders, including GAD. Better neuroscientific understanding may lead to new treatments for these conditions.

Anxiety disorders can run in families, but studies of twins suggest that heredity isn't the primary factor in developing GAD. The National Comorbidity Survey, conducted a decade ago, found that childhood adversity, especially traumatic experiences like sexual abuse, is strongly associated with adult GAD. Scientists are trying to learn how genetics and experience interact in anxiety disorders.

WHAT TO DO ABOUT GAD?
The first step is to seek professional help. Most people with GAD cannot "will" away their fears or talk themselves out of their anxiety. People with anxiety disorders generally respond well to treatment--sometimes in a few months, sometimes only after years.

Treatment is complicated by the fact that depression, alcohol or other drug addiction, and other anxiety disorders, such as panic disorder, can occur along with GAD and make it worse. Addressing any such co-existing condition is important for successful treatment.

Generally, no single therapy works for GAD, and several may be combined to individualize treatment.

Cognitive-behavioral therapy (CBT) works on the principle that learning to recognize the unrealistic thoughts that trigger anxious feelings will help a person modify both those thoughts and any associated behavior patterns. The individual works one-on-one with a therapist or in groups.
Psychotherapy, or "talk" therapy, involves sessions with a psychotherapist who focuses on the roots of a patient's anxieties to help her gain some control over them. It is often combined with CBT or medications. Psychotherapy can help an individual master the stress that contributes to GAD and overcome depression that results from living with a chronic condition.
Psychopharmacology is very useful in the treatment of GAD. Until recently, the anti-anxiety drugs known as benzodiazepines were the primary medications for anxiety disorders. They relieve symptoms quickly and are helpful for patients in whom anxiety is so severe that they can't engage in behavioral treatment or psychotherapy. People with drug or alcohol problems are not good candidates for benzodiazepines because they may become addicted.
Antidepressants, especially those in the class known as selective serotonin reuptake inhibitors (SSRIs), have found increasingly widespread use in the treatment of anxiety disorders and are often effective for people with GAD, even if they're not depressed. The SSRIs have relatively minor side effects and are non-addictive. But they generally require several weeks to become fully effective. Sometimes a benzodiazepine is prescribed along with an antidepressant in order to provide immediate relief from anxiety; then it's withdrawn while the antidepressant is continued.

Most patients find that relaxation and stress management, yoga, meditation, or self-help groups enhance their treatment. Preliminary evidence suggests that aerobic exercise helps reduce anxiety and stress and improves mood in people who are depressed. These effects may be due to the exercise-induced release of endorphins and mood-enhancing neurotransmitters.

Other lifestyle considerations, such as getting enough sleep, are also important. Caffeine and even some over-the-counter cold remedies should be avoided because they can aggravate the symptoms of anxiety disorders.

Types of Anxiety Disorders
Although each anxiety disorder has distinct symptoms, they all share a common theme of irrational fear or dread.

Generalized anxiety disorder (GAD). Excessive, unrealistic worry about day-to-day issues that lasts for several months, accompanied by physical symptoms such as headache, trembling, muscle tension, fatigue, and insomnia.

Panic disorder. Severe attacks of panic accompanied by physical symptoms such as heart palpitations, chest pain, or fear of dying or losing control. People with this disorder sometimes worry so much about having a panic attack in public or a place from which they can't escape that they become housebound with agoraphobia (fear of venturing out into the open).

Obsessive-compulsive disorder (OCD). Obsessions are repetitive thoughts and exaggerated concern about such things as contamination or improper behavior. Patients with OCD may perform compulsive rituals such as washing their hands or repeating phrases to relieve the anxiety caused by their obsessions.

Post-traumatic stress disorder (PTSD). An anxiety syndrome that may follow a traumatic event, such as a natural disaster, physical assault, or the death of a loved one. Patients with PTSD may have flashbacks or nightmares, avoid places related to the trauma, and feel emotionally numb or detached from others.

Social anxiety disorder, or social phobia. Extreme anxiety about being judged by others or about behaving in a way that might cause embarrassment. This disorder causes patients to avoid many social situations.

Specific phobias. Intense fear of a specific object or situation, such as dogs or snakes, heights, enclosed spaces, or crowds. Most patients recognize that the fear is irrational, yet feel compelled to avoid the feared situation in ways that interfere with daily life.

MEDICATIONS USED IN TREATING GENERALIZED ANXIETY DISORDER
Legend for Chart:

A - Class
B - Name
C - Comment

A B

C

Benzodiazepines alprazolam (Xanax),
chlordiazepoxide (Librium),
clonazepam (Klonopin),
diazepam (Valium),
halazepam (Paxipam),
lorazepam (Ativan),
oxazepam (Serax)

Enhances the function of the
brain chemical GABA.
Fast-acting, habit-forming,
can cause drowsiness. May
produce withdrawal symptoms
if discontinued too
quickly. Can be used "as
needed."

Antidepressants

Selective Serotonin citalopram (Celexa),
Reuptake Inhibitors fluvoxamine (Luvox),
(SSRIs) paroxetine (Paxil),
fluoxetine (Prozac),
sertraline (Zoloft)

Regulates serotonin levels
in the brain. May require
2-6 weeks to produce a
therapeutic effect. Fewer side
effects than benzodiazepines
and tricyclic antidepressants.
May cause nausea,
sleepiness, nervousness,
slight weight gain, and reduced
libido.

Azaspirones buspirone (BuSpar)

Enhances serotonin activity.
Somewhat less sedating
than benzodiazepines. Must
be taken for at least two
weeks to achieve an antianxiety
effect.

Tricyclics amitriptyline (Elavil),
imipramine (Janimine,
Tofranil).

Regulates serotonin and/or
noradrenaline activity in
the brain. May take 2-6 weeks
to become effective.
Possible side effects include
dry mouth, weight gain,
mild sexual side effects,
constipation, blurry vision,
low blood pressure.

Other nefazodone (Serzone),
venlafaxine (Effexor)

Affects serotonin and
norepinephrine levels in the
brain. Serzone may cause
sleepiness. Effexor's side
effects are similar to SSRIs'.
Selected Resources
National Institute of Mental Health
Anxiety Disorders
(301) 443-4513
www.nimh.nih.gov

Anxiety Disorders Association of America
(301) 231-9350
www.adaa.org

American Psychiatric Association
(202) 336-5500
www.psych.org

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