Anxiety is a general feeling of dread or apprehension. Anxiety disorders are characterized primarily by feelings of anxiety that are so intense or so frequent that they cause distress to or difficulty for an individual. Common symptoms are tension, nervousness, distress, or uncomfortable arousal - of varying levels of intensity, excessive worry and a concentration of thoughts on worrisome phenomena, and somatic symptoms associated with high arousal of the autonomic nervous system.
DSM-IV (see Treatment section) divides anxiety disorders into five main categories: phobias, panic disorders, generalized anxiety disorder, stress disorders (posttraumatic stress disorder and acute stress disorder), and obsessive-compulsive disorder. These various forms of anxiety disorders differ in their population frequencies. Anxiety disorders usually first appear in the late teens or early 20s. They are more common in people who are divorced, separated, or unemployed. Phobias and panic disorder are more common in women, and obsessive-compulsive disorder is more common in men. In particular, within the general population, 8% of all women are phobic, but only 3.5% of men are. All five disorders share several common symptoms that characterize them as anxiety disorders.
Anxiety disorders create mood, cognitive, somatic, and motor symptoms. Mood symptoms include feelings of tension, apprehension, and sometimes panic. Often, those who experience these symptoms do not know exactly why they feel the way they do. They may have a sense of foreboding or even of doom but do not know why. Sometimes, anxious persons become depressed, if only because they do not see any way to alleviate the symptoms.
Cognitive symptoms may include a person's spending a lot of time trying to figure out why various moood symptoms are occurring. When unable to identify the causes, the individual may feel frustrated. Often, thinking about the problem actually worsens it, making it hard for the person to concentrate on other things.
Typical somatic (e.g., bodily) symptoms include sweating, hyperventilation, high pulse rate or blood pressure, and muscle tension. All of these symptoms are characteristic of a high level of automatic nervous system arousal (see chapter 3). These primary symptoms may lead to secondary ones. For example, hyperventilation may lead to feelings of lightheadedness or breathlessness. Muscular tension can lead to headaches or muscle spasms or even cardiac problems. People who suffer anxiety disorders vary widely in the extent to which they experience somatic symptoms they experience. Some people may express their anxiety in headaches, others in stomachaches, and so on.
Typical motor symptoms include restlessness, fidgeting, and various kinds of bodily movements that seem to have no particular purpose (such as pacing, finger tapping, tics, and the like). People are often unaware that they are doing these things. For example, they may pace around a room while others are seated, not realizing how others are perceiving their behavior.
When is anciety a disorder? What distinguishes the normal anxiety that everyone occasionally experiences from debiliting anxiety? Generally, three factors must be considered:
One factor causing anxiety may be the stress brought on by modern society. This culturally based factor is suggested by the higher rates of anxiety disorders occuring in technologically advanced societies. The particular manifestations of symptoms and the grouping of symptoms into diagnosed disorders also varies across cultures, even modern ones. For example, in Japan, taijin-kyofusho (fear of humans) is a common manifestation of anxiety. This condition mainly affects males, and their symptoms include staring inappropriately, emitting offensive odors or flatulence, and blushing easily. The Japanese condition of taijin-kyofusho is significantly related to the Western condition of social phobia and to the Latin American condition of susto, characterized by extreme anxiety, restlessness, and fear of black magic and the evil eye (mal ojo), although each complex of symptoms reflects characteristics and values of the respective cultures.
Quite a different anxiety disorder has been observed in Islamic societies, in which the obsessive-compulsive syndrome of Waswas has been linked to the Islamic ritual of cleansing and prayer. The syndrome relates to ritual cleanliness and to the validity of the ritual procedures, which are particularly important in Islam. Thus, the sufferer of Waswas finds it hard to terminate the ablutions because he is afraid that he is not yet clean enough to carry out his prayers in a lawful manner.
As you might expect, the different theoretical approaches lead to alternative explanations for the origin of anxiety disorders. Here as elsewhere, these explanations are not necessarily mutually exclusive and may even be wholly compatible, in that disorders may have multiple causes or causes that coexist at different levels of analysis. Researchers seldom find a single element that causes a psychological phenomenon. Instead, as each of several factors comes to light, each new insight contributes to an increasingly detailed picture of the phenomenon.
The emphasis in psychodynamic explanations is on internal conflict. Freud distinguished among three types of anxiety and believed each requires a distinct explaination. The first of these three types, objective anxiety, derives from threats in the external world. Included here would be anxiety about realistic financial problems, failure in work or in personal relationships, serious illnesses, and the like. This kind of anxiety would correspond to fear, as it was defined in our previous distinction between anxiety and fear. Freud maintained that this kind of anxiety is not linked to abnormal behavior because the threat causing the anxiety is real.
The second and third types of anxiety stem from battles between the id and the superego. Moral anxiety derives from fear of punnishment by the superego, which arrises from conflict within the person over expression of impulses from the id. After the impulses of the id have worn out and are expressed, the person experiences moral anxiety. For example, a poorly qualified, dull candidate who seeks to win an election might attempt to win by smearing an opponent. Later, this person might experience some degree of moral anxiety. By giving in to impulses to succeed at the other person's expense, the candidate created internal conflict.
Neurotic anxiety derives from a person's fear that the superego (with the aid of the ego) will not be able to control the id and that the person may not be able to avoid in engaging in unacceptable behavior. For example, a person may be afraid to go out on a date with a particularly attractive person for fear of acting in an unacceptable way, and thereby losing the potential for a relationship with the attractive person. Note that the neurotic anxiety occurs before the impulses of the id have been expressed and while the superego is still restraining its expression.
Freud believed that phobias occur when anxiety is focused on one or more particular objects; these objects represent a conflict at a symbolic level. For example, a phobia of snakes might symbolically represent sexual conflict, whereby the snake serves as a phallic symbol to focus the anxiety. Freud believed that many anxieties originated in sexual conflicts. In contrast, many neo-Freudians believed other important conflicts, such as those centered on feelings of inferiority or of attachment could also lead to anxiety in a number of instances. In any case, the evidence for psychodynamic interpretations of anxiety is relatively weak.
The emphasis in learning-theory explanations is on conditioned fears and observational learning. Many learning (or behavioral) theorists view anxiety as being classically conditioned. According to this thinking, a fear response has been paired with a stimulus that was previously neutral. Thus, what was a previously neutral stimulus is now a fear-producing one. For example, a person might have a neutral or slightly favorable attitude towards dogs. Then one day the person is seriously bitten by a dog. Through classical conditioning, the person becomes anxious in the presence of dogs, or possibly even at the thought of dogs. As it turns out, about 44% of people with social phobia can identify a traumatic conditioning experience that they believe has contributed to their problem.
According to classical learning theory, the unpleasant experience would have to happen to the individual experiencing the anxiety for conditioning to occur. According to contemporary forms of learning theory, however, it is possible to experience vicarious conditioning. Simply through observational learning, we can be conditioned to experience anxiety. For example, most of us, thankfully, have not contracted acquired immune deficiency syndrome (AIDS). By observing the effects of AIDS, however - on television or through friends or family - we could become anxious about AIDS and even phobic about the possibility of contracting AIDS, solely through having been vicariously conditioned.
Operant conditioning can also play a part in the development of anxiety disorders. Consider, for example, compulsive behavior. Suppose that you have an irrational fear of bacteria. Washing your hands makes you feel safer, at least temporarily. You are thereby reinforced for the hand-washing behavior, but soon the fear returns. You have learned that hand washing helps alleviate anxiety, so you wash your hands again. The anxiety is alleviated again, but not for long. In this way, you have learned to engage in the compulsive behavior because it temporarily alleviates anxiety, as a result of operant conditioning.
Cognitive explanations emphasize automatic self-defeating thoughts. Suppose a woman wants to ask a man out to lunch, but the thought of actually picking up the phone and calling him makes her sweat with anxiety. She starts thinking, "I know I'm going to fail. I know he's going to just put me down. I'd really like to invite him, but I just can't stand being rejected again." These kinds of thoughts produce anxiety, causing people to be unable to do some of the things that they would like to do. These thoughts are likely to become automatic thoughts - thought patterns that people seem to fall into without being aware of them and that they experience without effort. Often, such thoughts are the beginning of a self-defeating cycle. Someone who expects rejection may feel spurned when receiving neutral cues or may find seeds of repudiation even in positive things that another person says. Thus, anxiety disorders tend to be self-propagating. In general, the thoughts are not of what is happening at the moment, but of what is expected to happen.
One humanistic explanation for anxiety disorders is that the person experiences a discrepancy between the perceived self and the idealized self, causing feelings of failure. These feelings of failure cause the anxiety. Anxious people tend to indicate more of a discrepancy than do confident people between the persons they believe they are and the persons they believe they should be. Anxious people also show lower social skills than do nonanxious people, which may further reduce their confidence in themselves.
Several biological explanations for anxiety disorders have been proposed. One explanation suggests that inhibitory neurons that serve to reduce neurological activity may function improperly in people with anxiety disorders. For example, insufficient levels of the neurotransmitter GABA (gamma-aminobutyric acid) lower activity in the inhibitory neurons and thereby increase brain activity; the result is a high level of arousal, which can be experienced as anxiety. Drugs that decrease GABA activity lead to increasing anxiety. Various tranquilizers, such as diazepam, increase GABA activity and thereby decrease anxiety. There also appears to be a link between a gene that controls the brain's activity to use serotonin and anxiety-related behavior. Research suggests that anxiety disorders often run in families.