Fear is the driving force behind anxiety disorders. Each of us experiences fear throughout the course of our lives. But instead of feeling the reasonable fear that helps us recognize and respond to immediate danger, such as narrowly avoiding a trafﬁc accident, people with an anxiety disorder experience fear that occurs in response to dangers that are either imagined or not immediately threatening. Such people experience almost constant feelings of worry or dread that interfere with their daily activities, along with symptoms of anxiety such as rapid heart- beat and increased perspiration.
Anxiety disorders are the most prevalent mental disorders in adults. About
30 million people in the United States have some type of anxiety disorder, and twice as many women as men are affected. Anxiety disorders appear to arise from a combination of stressful life experiences, psychological traits, and genetic inheritance, although certain disorders—such as panic disorder (see page 352)—appear to have a stronger genetic component than others. The most common anxiety disorders include generalized anxiety disorder, phobias, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder.
Generalized Anxiety Disorder
People who have generalized anxiety disorder experience ongoing but unrealis- tic worry or dread about the circumstances of daily life. The excessive worries often pertain to many areas of the affected person’s life, including work, rela- tionships, ﬁnances, personal health, the well-being of one’s family, perceived misfortunes, and impending deadlines. Affected people can experience a variety of symptoms, including feelings of fear and dread, restlessness, muscle tension, a rapid heart rate, light-headedness, poor concentration, insomnia, increased per- spiration, cold hands and feet, and shortness of breath. Symptoms typically worsen during stressful periods.
Generalized anxiety disorder affects only half as many men as women. It begins in childhood or adolescence in about 50 percent of affected people but does not seem to run in families.
There are three major types of phobias: speciﬁc phobias, social phobias, and agoraphobia. Speciﬁc phobias are those triggered by fear of a speciﬁc object, such as snakes or spiders. Claustrophobia (fear of enclosed spaces), acrophobia (fear of heights), and fear of ﬂying or driving also fall into this category. About
8 percent of American adults experience one or more speciﬁc phobias in any given year. Typically developing in childhood, many speciﬁc phobias disappear by adulthood. Those that last into adulthood usually require treatment.
Social phobia describes persistent anxiety in social situations, based on fear of embarrassment or ridicule. People with a social phobia become preoccupied with concern that other people will notice their anxious symptoms—such as blushing, sweating, or trembling—or that their mind will go blank when speak- ing to someone else. Like stage fright, social phobia causes intense fear when the person is aware that other people can observe him or her doing even simple things, such as eating a meal in a restaurant or putting on a coat. A more general form of the disorder provokes fear during most interactions with other people. People with a social phobia often avoid socializing and even can have difﬁculty attending school or keeping a job. Performance anxiety and fear of public speak- ing also fall into this category of phobias. Social phobia affects men and women in equal numbers and usually develops in childhood or adolescence. It has been linked to shyness and tends to run in families.
Agoraphobia, a term that literally means “fear of the open marketplace,” refers to fear of being in public places, such as streets, shopping malls, theaters, airplanes, and other places where people gather. People with agoraphobia fear that they will not be able to escape from a given place or that no one will be available to help them in such circumstances. People with agoraphobia often do not venture out of their homes unless accompanied by someone else. Agora- phobia is the most serious type of phobia because in the most extreme cases,
affected people refuse to leave their homes at all. The disorder most often devel- ops from the constant worry, preoccupation, and avoidance that occurs following a series of panic attacks (see below). Agoraphobia occurs twice as often in women as in men.
Many doctors use desensitization techniques to treat phobias. Desensitization involves gradually exposing a person to the trigger (object or situation that he or she fears) in an attempt to teach the person to react without fear. Medication and psychotherapy also are typically used to treat phobias.
Panic attacks are brief and very intense episodes of a high level of anxiety that often occur with no apparent cause. A panic attack can produce sweating, short- ness of breath, rapid heart rate, chest pain, numbness or tingling, trembling, and nausea or stomach pains. Most affected people also report feeling that they are losing control, “going crazy,” or dying. An attack typically starts suddenly and builds to its maximum intensity in 10 to 15 minutes, rarely lasting more than 30 minutes. The experience provokes a strong urge to ﬂee and often causes the per- son to seek help at a hospital emergency department. After the person experi- ences one or more panic attacks, he or she begins to anticipate more of them and may begin to avoid activities or situations, such as riding in an elevator, that seem to trigger them. Anxiety caused by merely thinking of the possibility of another attack can cause the person to become reclusive. Extreme cases of panic disorder can lead to agoraphobia (fear of being in public places).
Panic disorder is about twice as common in women as in men. Typically the disorder ﬁrst appears between late adolescence and middle age. Panic attacks do not always indicate an underlying mental illness; up to 10 percent of people experience an isolated panic attack each year. A panic disorder can occur when other mental disorders, such as social phobia (see previous page), generalized anxiety disorder (see previous page), or depression (see page 345), also are pres- ent. Doctors can conﬁrm a diagnosis of panic disorder when the person has experienced at least two panic attacks and develops persistent concern about having additional attacks.
Obsessions are recurrent, intrusive thoughts, impulses, or images that the affected person perceives as being inappropriate, grotesque, or forbidden. These thoughts seem unlike the person’s usual thoughts and can cause anxiety and dis- tress. The obsessions also seem uncontrollable, and the person becomes afraid that he or she will lose control and act upon them. Common themes of obses- sions include contamination with germs, worry that the person has unknowingly inﬂicted harm upon someone else, or loss of control over violent or sexual impulses.
Compulsions, on the other hand, are repetitive behaviors or patterns of thought that reduce the anxiety that accompanies an obsession or that “prevent” some dreaded event from occurring. Compulsions can take the form of repeated, ritualistic patterns of hand washing, checking, counting, or praying. For exam- ple, the person may count to ten 30 times or may count backward. He or she may recite a certain prayer or passages from the Bible in a speciﬁc sequence. Com- pulsive rituals can consume long periods of time. The presence of both obses- sions and compulsions constitutes obsessive-compulsive disorder.
Obsessive-compulsive disorder affects about 21⁄2 percent of Americans and is equally common among men and women. It typically begins in adolescence or young adulthood in males. As with generalized anxiety disorder (see page 351), symptoms tend to worsen during stressful periods. There is strong evidence that the disorder runs in families.
Posttraumatic Stress Disorder
Posttraumatic stress disorder refers to the anxiety and disturbances in behavior that develop after experiencing an extreme trauma, such as witnessing a murder, experiencing torture, being in a serious accident, or participating in military combat. A critical feature of posttraumatic stress disorder is the psychological symptom of dissociation, a perceived detachment of the mind from the person’s emotional state or even from the body. Dissociation is also characterized by a dreamlike or unreal perception of the world and may be accompanied by poor memory of the traumatic event. Other symptoms of posttraumatic stress disorder include general anxiety, a heightened sense of arousal, avoidance of situations that elicit memories of the trauma, and intrusive recollections of the event in ﬂashbacks, dreams, or recurrent thoughts. Symptoms of the disorder may be immediate or delayed, beginning 6 months or more after the traumatic event.
A person with posttraumatic stress disorder experiences decreased self- esteem and a loss of long-held beliefs about people or society. He or she begins to feel hopeless and permanently damaged by the traumatic experience and begins to have difﬁculty with personal relationships. Substance abuse often develops as the person attempts to relieve such feelings by using alcohol, mari- juana, or sedatives.
Posttraumatic stress disorder is most common among women who are rape victims. Women are twice as likely to have the disorder as men. The disorder is also common in concentration-camp survivors and Vietnam War veterans. About half of all people with posttraumatic stress disorder recover within 6 months. For the others, the disorder typically persists for years and may dominate their lives.
Treatment of Anxiety Disorders Anxiety disorders are usually treated with some form of counseling or psychotherapy (see page 347), often combined with drug treatment. Doctors now use more focused, time-limited forms of therapy
that teach the affected person how to cope with the symptoms of anxiety rather than exploring unconscious conﬂicts. A critical element of such therapy is gradual but increasing exposure to the object or situation that causes the anxiety in order to stop the affected person from avoiding anxiety-inducing situations.
Medications that doctors typically prescribe to treat anxiety disorders are those that readjust imbalances in neurotransmitters (chemicals that carry mes- sages between brain cells). Such medications include benzodiazepines, antide- pressants (such as paroxetine or ﬂuoxetine), and an antianxiety medication called buspirone. Benzodiazepines such as clonazepam, diazepam, and lorazepam have antianxiety and sedative effects but can be habit-forming. Buspirone is useful for treating generalized anxiety disorder and, unlike the benzodiazepines, is not addictive.
The amount of sleep needed each night varies from person to person, but most healthy men need 8 to 81⁄2 hours of sleep per night to be fully alert during the day. If a man does not get enough sleep—even for one night—he may experi- ence drowsiness that disrupts his daily routine.
Certain medical conditions and drugs also can interrupt sleep and cause day- time drowsiness. Problems such as asthma (see page 245), congestive heart fail- ure (see page 233), and rheumatoid arthritis (see page 309) or any other painful condition can keep you from getting a good night’s sleep. Medication used to treat high blood pressure or heart disease, and asthma medications such as theo- phylline, also can interfere with sleep. Alcohol can help you to fall asleep but causes sleep disruption later in the night and can produce early morning headaches. The sedative effects of alcohol also can put you at increased risk for motor vehicle collisions if you drink and drive. Caffeine, which stays in the body for 3 to 7 hours after ingestion, makes it harder to fall asleep and stay asleep. The nicotine in cigarettes and nicotine patches is a stimulant that also can disrupt sleep.
Many men who work the night shift have difﬁculty sleeping. Most night-shift workers get less sleep overall than day workers. The human sleep-wake cycle is designed to prepare the body for sleep at night and wakefulness during the day. These natural rhythms make it harder for a person to sleep during the day and to work at night. In addition, lights, noise (such as from telephones), and family members can be annoying distractions that disrupt daytime sleep.
If you have problem with sleepiness, monitor your sleep-wake patterns. If you are consistently getting fewer than 8 hours of sleep per night, try to get more sleep by gradually moving to an earlier bedtime. If your schedule does not per- mit you to go to bed earlier, try to squeeze in a 30- to 60-minute daily nap. If you are sleepy, do not drive; sleepiness will increase your risk of having a collision.
If you think you are getting enough sleep but still feel sleepy during the day,
you may have a sleep disorder. Talk to your doctor, who can evaluate your symp- toms and prescribe appropriate treatment.
Some men have medically recognized sleep disorders. The most common sleep disorders are insomnia, sleep apnea, narcolepsy, and restless legs syndrome.
Most people need a full 8 hours of sleep, while some can function well with less. Many people, however, are unsatisﬁed with the amount of sleep they get. Insom- nia refers to inadequate or poor-quality sleep, usually the result of difﬁculty falling asleep, frequent waking during the night, or rising too early in the morn- ing. Once the person wakes during the night or early in the morning, he or she has difﬁculty going back to sleep. Insomnia can cause fatigue, lack of energy, difﬁculty concentrating, and irritability.
Insomnia that lasts only a few weeks or less is called transient insomnia. If episodes of insomnia occur from time to time, the problem is called intermittent insomnia. Insomnia that occurs on most nights and lasts a month or longer is called chronic insomnia.
Factors that may contribute to insomnia include being older and having a his- tory of depression (see page 345). Although insomnia occurs in men and women of all ages, it seems to be more common in women and older people. Transient insomnia and intermittent insomnia often occur in people who are experiencing temporary problems such as stress, noisy sleeping conditions, extreme heat or cold, jet lag, or side effects of medications.
The causes of chronic insomnia are more complex, often involving a number of underlying disorders. One of the most common causes of chronic insomnia is depression (see page 345). Other causes include arthritis (see page 308), kidney disease (see page 288), heart failure (see page 233), asthma (see page 245), sleep apnea (see next page), narcolepsy (see page 357), restless legs syndrome (see page
358), Parkinson’s disease (see page 337), and hyperthyroidism (see page 374).
Lifestyle factors such as overuse of caffeine, alcohol, or other drugs; shift work; smoking cigarettes before bedtime; excessive daytime napping; or chronic stress also have a role in the development of insomnia. Stopping these behaviors may help eliminate insomnia.
If you have insomnia, your doctor will take a complete health history (see page 82) and a sleep history. To obtain a sleep history, the doctor will ask you to keep a sleep diary or interview your sleep partner to ﬁnd out how much sound sleep you typically get each night. Transient and intermittent insomnia may require no treatment because it often clears up when the underlying problem, such as jet lag, is resolved. If your daytime performance is adversely affected by transient insomnia, your doctor may prescribe a short-acting sleeping pill for a brief period.
To treat chronic insomnia, your doctor will f irst diagnose and treat any
underlying medical or psychological problems you may have. He or she may prescribe a sleeping pill, but only for a brief period to minimize unwanted side effects or dependence on the pills for sleep. Certain behavioral techniques also are often used to improve sleep. One such technique is relaxation therapy, which is used to eliminate anxiety and muscle tension. Some people with insomnia beneﬁt from sleep restriction, which at ﬁrst allows only a few hours of sleep each night, and gradually increases sleep time to a more normal span of time. Another helpful treatment is called reconditioning, which teaches the affected person to associate the bed and bedtime with sleep by avoiding use of the bed for any activity other than sleep or sex.