Anxiety disorder is an unpleasant mood of tension and apprehension. It is fear’s first cousin and, like fear, has prominent autonomic effects when severe. But fear is an emotion sharply focused on immediate dangers, whereas anxiety is usually imposed by the anticipation of future danger, distress, or difficulties. As an emotional response common to all men, anxiety is useful. Activities that arouse it are avoided and those that diminish it are sustained. Although anxiety may spur people to perform difficult tasks skillfully and admirably, when excessive it is a hindrance, as some well prepared students demonstrate when facing a critical examination. Anxiety is a medical problem when it is excessive, inappropriate, or without obvious cause.
Predisposing and Precipitating Factors.
Anxiety is the psychologic response to anticipated troubles, real or imagined, dimly or accurately perceived. But men and troubles vary. Some persons, the timid, the inexperienced, the excessively conscientious, are frequently anxious over trivia. Other men seem unaffected by the same experiences. Most people are at least mildly anxious whenever they seek medical advice, and when threatening dangers are intense or prolonged, as in chronic painful illness or in battle, even the most resistant individuals can develop incapacitating anxiety.
Resistance to anxiety varies with physical condition.
When tired, sick, or injured, people are more easily threatened than when fresh. Also, they are more vulnerable to anxiety when their powers of analysis and discrimination are failing or underdeveloped. Thus, because of inadequate comprehension or imprecise perception, the immature, the elderly, or the person with brain damage may become anxious in situations in which a person with a healthy, mature brain is comfortable. In fact, one of the first indications of a beginning dementia can be an attack of severe anxiety without obvious provocation.
Common precipitance of anxiety in daily life are circumstances of conflict in which an action is demanded but the correct action may be difficult to discern. Thus, a person may be anxious over difficult decisions on which rest his economic and social success or because the decisions produce an unpredictable response in an inconsistent superior. Laboratory models for this kind of situation and its effects on the emotional state have been easy to produce. Pavlov trained’dogs to respond to the picture of a circle by rewarding such responses with food. He did not reward responses to an ellipse. Then, by simply compressing the ellipse so that it gradually approached a circle in shape, he made the discrimination progressively more difficult.The emotional response of these dogs was remarkable.
They beca ferocious and violent when put into harness fi the experiment. They tore at their restrain barked uncontrollably, and refused to attempt the discrimination. In this state, not only did the; make many mistakes, but they became unable t. make discriminations that had previously been easy. It is not difficult to see analogies in both situation and behavior between Pavlov’s dogs and men with emotional conflicts.
An emotional state of anxiety can be produced in other ways than as an understandable response to anticipated difficulties. An intractable anxiety state can follow a severe head injury as one of the symptoms of the so-called post-concuSsio syndrome. Similarly, a mood of tension and agitation with tremulousness can occur in the delirious states, such as those that follow withdrawal of alcohol or barbiturates and are sometimes produced by the hallucinogenic drugs such as LSD-25. In these situations, it may be disturbed perceptions and misinterpretations that arouse anxiety, but often the anxiety is independent of anything that the patient definitely experiences or understands. Roth describes a peculiar and chronic anxiety state that can follow a calamitous emotional experience.
This condition, referred to as the phobic anxiety syndrome, occurs in mildly obsessional persons after a severe fright. The disturbance can last for many months. These patients are in a state of considerable anxiety, mostly unformulated, and, associated with this, they have an unwillingness to leave their homes because of vague fears. The peculiar psychologic response of depersonalization, which is a change in the awareness of self such that the person feels unreal, is present in many of these patients. In the phobic anxiety syndrome the mood of anxiety follows rather than precedes difficulty, demonstrating that anxiety, normally an anticipatory psychologic response, may take on a self-sustained activity after certain experiences such as severe frights or sudden disasters.
The role of learning and of conditioning has too often been neglected in considerations of anxiety. This probably derived from attempts to explain all anxiety in terms of basic instinctive drives. That a fear-provoking situation could train an individual to experience symptoms of anxiety in circumstances that resembled these situations is very likely, and is indicated by research on emotion in animals. The capacity to develop anxiety via conditioning mechanisms seems the probable explanation for certain cases of phobic anxiety focused on specific objects.
Manifestations of Anxiety.
The manifestations of anxiety are divisible into three groups. First are the inner feelings of tension, apprehension, and dread that form the anxious mood itself. Second are disturbances of the intellectual power of the anxious patient. He is unable to think clearly, to use proper judgment, to learn efficiently, or to remember accurately. Third are the autonomic, visceral, and endocrine changes that have been analyzed by Walter B. Cannon and his followers as the constant companions of emotional excitement and particularly of anxiety or fear. These include tremor, tachycardia, hypertension, increased perspiration, dilated pupils, and reduced salivation and gastric secretion. Increased activity of the sympathetic nervous system and of the adrenal medulla mediates the majority of these visceral responses to anxiety.
A model anxiety state is to be seen among front-line soldiers. The infantryman is a prepared subject for anxiety. He is always threatened with death or mutilation. He must go without sleep, remain exposed to the weather, and often be hungry. He is usually unable to understand what is happening around him. He is repeatedly frightened by gun fire and distressed by the death of comrades. If he is exposed long enough, he develops a severe and persisting anxiety state sometimes called “battle fatigue.” He becomes tense and easily startled. His judgment is poor, and he cannot efficiently sustain a complex offensive action. Among other physical complaints, he suffers from headache, anorexia, and diarrhea.
He is usually convinced that death is imminent. Almost all men develop this condition if exposed to battle long enough. Wolff reports that the average man in the army of the United States reached this point after 85 days of combat; 75 per cent could be expected to break down by combat day 140, and 90 per cent by combat day 210. These figures vary little among nations, although few are willing to publish them. They make the point that, in his resistance to crippling anxiety, even the bravest man has a “breaking point.” On reaching it, he does not betray his group or run from the enemy, but rather he becomes less efficient in protecting himself and runs a high risk of death.
The symptoms of anxiety that physicians see in patients are not different. The patients all have the same three groups of symptoms, but, depending in part on the cause, these symptoms can appear as a relatively brief attack or as a more prolonged, chronic disturbance of mood.
Causes of Anxiety Disorder And Panic Attacks: How Long Panic Attack Last
Anxiety attacks may be single episodes occurring in response to some acute threat, or may be periods of exacerbation in a chronic state of tension. They are short periods of tension, varying in. severity from mild apprehension to severe panic. An anxiety attack can occur at any time. A curiously favored time is when the patient is traveling in -a plane or fast train. Most commonly, though, an attack develops at night when, with the disappearance of daytime distractions, a patient begins to ruminate on his troubles. The apprehensions grow to preoccupy his though tsf and he develops visceral responses to fear. Clear thinking becomes impossible, as does sleep. The heart pounds. A common complaint in an anxiety attack is the sensation of tightness in the chest as though the lungs could not be adequately filled. The patient responds to this sensation by deep and sighing respirations. Sometimes he may produce in this way a respiratory alkalosis with feelings of giddiness and vertigo, tingling of his fingertips, and even tetany with carpopedal spasm. This is the hyperventilation syndrome, and the resulting symptoms may add anxiety.
Full-blown anxiety attacks have a hysterical flavor and may, in part, depend on personal tendencies to self-dramatization and suggestibility. But they also can be the results of a psychic chain reaction, the initial apprehensions and anxiety stirring up cardiac and respiratory changes that are themselves frightening. Granville-Grossman and Turner have provided more evidence that visceral responses to anxiety can increase the subjective symptoms of anxiety by demonstrating that these latter symptoms are improved when an anxious patient is treated with propranolol, a drug that blocks the adrenergic beta-receptors of the sympathetic nervous system and slows the heart rate.
Chronic anxiety may be punctuated by or may begin with an acute attack, but it may be just a steady and ‘distressingly prolonged disturbance of mood. The symptoms are less intense although not different in quality from those of acute anxiety. The patient is tense and “on edge.” He may also report some feelings of sadness or hopelessness along with his anxiety. It can be difficult to differentiate his condition from an agitated depression. Hisi intellectual powers are diminished, and he has considerable difficulty in concentration and in thinking. He will score poorly on intelligence tests, particularly on the performance subtests, just as does a patient with dementia.
He will have a number of somatic complaints: frontal 6r occipital headache, anorexia, diarrhea, and weight loss, among other things. On examination, he may have the physical signs of tension, a fine tremor of the extended arms and brisk tendon reflexes, rapid heart beat, increased blood pressure, and pupillary dilatation. More extensive laboratory studies may reveal other visceral and endocrine disturbances, such as reduced gastric acid secretion or increased adrenocortical activity.
Anxiety Disorder Diagnosis.
Usually diagnosis is not difficult. In both acute and chronic anxiety, the patient’s major complaint is the distressing emotional state. Associated disturbances in thinking and autonomic function serve to confirm the diagnostic impression. For these patients, the major issue is not the diagnosis of anxiety, but rather the question of why they have become anxious now. This question must be answered from knowledge of the circumstances and personality of the patient.-
An occasional patient focuses his complaints on his physical symptoms, such as irregularities in the beat of his heart, the change in bowel habits, weight loss, anorexia, or easy fatigability. From these symptoms a more severe illness such as a hidden malignancy, a chronic infection, or some endocrine disorder like hyperthyroidism or Addison’s disease may be suspected. Although these conditions are usually seen to be only remote possibilities, laboratory studies may be required to exclude them. As with all psychologically disturbed patients, laboratory studies should not be delayed or protracted but should be decided upon, and this phase of the examination should be finished as promptly as possible.
Anxiety Disorder Treatment.
Treatment will vary with the cause and severity of anxiety. Many mildly anxious patients can be helped by a physician who is willing to listen carefully to their difficulties and offer some support and occasional advice. Most patients with anxiety have this mild type. Their disturbances are transient and are based on some particular problem or self-doubt that has developed acutely and is eventually resolved.
- Those with more severe anxiety can be aided by a combination of pharmacologic treatment and repeated compassionate discussions of their troubles. Barbiturates have been the preferred agents for relief of anxiety in the past. However, barbiturates can be addictive, and there is the ever-present danger that they may be used in a suicide attempt by an anxious patient who is also depressed. In several double-blind clinical trials, chlordiazepoxide (Librium) has been found as effective as barbiturates for treating anxiety, and can be recommended. Dosage of 10 mg. three to four times a day is usually effective. Up to 20 to 25 mg three times daily can be given to severely disturbed patients.
- Patients with persisting anxiety can be referred with some confidence to specialists in psychotherapy The effectiveness of psychotherapy seems to depend on the comfort provided by frequent sympathetic discussions and an increased recognition by the patient of the irrational’ aspects of his anxiety. The particular school of psychotherapeutic theory subscribed to by the therapist seems less important.
- Only the most severely anxious patients need hospitalization and then usually only for an acute attack of anxiety They are treated best with sedation, and often heavy sedation is necessary. Sodium amytal, in doses of 200 to 300 mg. every four to six hours, is the sedative of choice. The somatic symptoms from the respiratory alkalosis of the hyperventilation syndrome can be treated by placing a bag over the nose and mouth that will retain the expired C02 for breathing.
- Careful consideration should be given to any evidence that the anxious patient may be depressed. Agitated depression, as has been stated, can be easily confused with simple anxiety If depression is thought to be an important feature, then antidepressant medication, such as imipramine, 25 to 50 mg. three to four times a day, should be given rather than tranquilizers.
- For those individuals with restricted anxieties prompted by particular stimuli, i.e., phobias, there is growing evidence that reconditioning techniques based on learning theory may have an important place in therapy. Certainly some impressive controlled trials have been published indicating a faster response to this mode of management than to interpretive therapy for individuals suffering from a single phobia. This treatment, like any other, should hot be attempt without experience and guidance.
- A few chronically anxious patients do improve despite years of psychologic treatment.
