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Dr. Zabrin Inan, MD
Child, Adolescent and Adult Psychiatry
 Chicago

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Anxiety Disorders

Anxiety Disorders and the Brain: A Brief Overview
Several parts of the brain are key actors in a highly dynamic interplay that gives rise to fear and anxiety. Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions.

Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, and trigger a fear response or anxiety. It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts of the amygdala may be involved in other forms of anxiety.

Other research focuses on the hippocampus, another brain structure that is responsible for processing threatening or traumatic stimuli. The hippocampus plays a key role in the brain by helping to encode information into memories. Studies have shown that the hippocampus appears to be smaller in people who have undergone severe stress because of child abuse or military combat. This reduced size could help explain why individuals with PTSD have flashbacks, deficits in explicit memory, and fragmented memory details of the traumatic event.

Research also tells us that other brain parts called the basal ganglia and striatum are involved in obsessive-compulsive disorder.

The National Institute of Mental Health research-supported studies of twins and families suggest that genes play a role in the origin of anxiety disorders.  But heredity alone can't explain what goes awry. Experience also plays a part.  In PTSD, for example, trauma triggers the anxiety disorder; but genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD.

Unlike the relatively mild, brief anxiety caused by a stressful event, anxiety disorders are chronic and relentless.  Without treatment, they can worsen to cause the sufferer overwhelming anxiety and fear.

Anxiety disorders include:

Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread.

FOR MORE INFORMATION
Brochures and information about Anxiety Disorders
are available at:
www.nimh.nih.gov.

It is important to recognize that depression often accompanies anxiety disorders, and the depression needs to be treated as well. Symptoms of depression include feelings of sadness, hopelessness, changes in appetite or sleep, low energy and difficulty concentrating. Most people with anxiety and depression disorders can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of both.  

Let�s take a brief look at each of these anxiety disorders.

Panic Disorder

Panic disorder most often begins during late adolescence or early adulthood. The risk of developing panic disorder appears to be inherited. Not everyone who experiences panic attacks will develop panic disorder--many people have one attack but never have another.  For those who do have panic disorder, however, it is important to seek treatment.  Left untreated, the disorder can become disabling.  Fortunately, panic disorder is one of the most treatable of the anxiety disorders, responding in most cases to medications or carefully targeted psychotherapy.

If you are having a panic attack, most likely your heart will pound and you may feel sweaty, weak, faint or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have nausea, chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. You may genuinely believe you're having a heart attack or losing your mind, or on the verge of death. Panic attacks can occur at any time, even during sleep. An attack generally peaks within 10 minutes, but some symptoms may last much longer.

Many people with panic disorder visit the hospital emergency room repeatedly, or see a number of doctors before they obtain a correct diagnosis. Some people with panic disorder may suffer for years without learning that they have a treatable illness.

Panic disorder is often accompanied by other serious conditions such as depression, drug abuse or alcoholism and may lead to a pattern of avoidance of places or situations where panic attacks have occurred.

The disorder can lead some people to restrict their lives so that they avoid normal, everyday activities such as grocery shopping or driving. In some cases they become housebound. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, these people avoid any situation in which they would feel helpless if a panic attack were to occur.  This self-imposed restriction occurs in about one-third of people with panic disorder.  The condition is known as agoraphobia.  Early treatment of panic disorder can often prevent it.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD), involves anxious thoughts or rituals you feel you can't control. If you have OCD, you may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals. Such activities consume at least an hour a day, are very distressing, and interfere with daily life.

You may be obsessed with germs or dirt, so you wash your hands over and over. You may be filled with doubt and feel the need to check things repeatedly. You may have frequent thoughts of violence, and fear that you will harm people close to you or they may be harmed by someone else. You may spend long periods touching things or counting; you may be preoccupied by order or symmetry; you may have persistent thoughts of performing sexual acts that are repugnant to you; or you may be troubled by thoughts that are against your religious beliefs.

The disturbing thoughts or images are called obsessions, and the rituals that are performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the anxiety that grows when you don't perform them.

Most adults with this condition recognize that what they're doing is senseless, but they can't stop it. Some people, however, particularly children with OCD, may not realize that their behavior is abnormal.

OCD strikes men and women in approximately equal numbers. It usually first appears in childhood, adolescence or early adulthood. One-third of adults with OCD report having experienced their first symptoms as children. The course of the disease is variable--symptoms may come and go, they may ease over time, or they can worsen. Research suggests that OCD might run in families.

Depression or other anxiety disorders may accompany OCD. Some people with OCD also have eating disorders.  Some with OCD may try unsuccessfully to use alcohol or drugs to calm themselves. 

If OCD grows severe enough, it can prevent holding down a job or carrying out normal responsibilities at home.

OCD generally responds well to treatment with medications or carefully targeted psychotherapy.

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a debilitating condition that can develop following a terrifying event. Often, people with PTSD have persistent, frightening thoughts and memories of their ordeal.  They feel emotionally numb, especially toward people with whom they once were close.

PTSD was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include violent attacks such as mugging, rape or torture; being kidnapped or held captive; child abuse; serious accidents such as car or train wrecks; and natural disasters such as floods or earthquakes. The event that triggers PTSD may be something that threatened the person's life or the life of someone close to him or her.  Or, it could be something witnessed, such as massive death and destruction after a building is bombed or a plane crashes. Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day.

PSTD sufferers also may experience other sleep problems, feel detached or numb, or be easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Things that remind them of the trauma may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the traumatic event are often very difficult.

PSTD can occur at any age, including childhood, and there is some evidence that susceptibility to PTSD may run in families.

The disorder is often accompanied by depression, substance abuse, or one or more other anxiety disorders. 

In severe cases, the person may have trouble working or socializing.  In general, the symptoms seem to be worse if the event that triggered them was deliberately initiated by a person, for example, a rape or kidnapping.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A person having a flashback, which can come in the form of images, sounds, smells or feelings, may lose touch with reality and believe that the traumatic event is happening all over again.

Not every traumatized person gets full-blown PTSD, or experiences PTSD at all.

PTSD is diagnosed only if the symptoms last more than a month. In those who do develop PTSD, symptoms usually begin within three months of the trauma, and the course of the illness varies.

Some people recover within six months; others have symptoms that last much longer.  In some cases, the condition may be chronic.  Occasionally, the illness doesn't show up until years after the traumatic event.

People with PTSD can be helped by medications and psychotherapy.

Social Phobia

Social phobia involves overwhelming anxiety and excessive self-consciousness in everyday social situations.  People with social phobia have a persistent, intense and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school, and other ordinary activities.  While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.

Women and men are equally likely to develop social phobia.  The disorder usually begins in childhood or early adolescence, and there is some evidence that genetic factors are involved.

Social phobia often co-occurs with other anxiety disorders or depression.  Substance abuse or dependence may develop in individuals who attempt to "self-medicate" their social phobia by drinking or using drugs.

Social phobia can be limited to only one type of situation--such as a fear of speaking in formal or informal situations, or eating, drinking or writing in front of others.  In its most severe form, the phobia may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating; it can prevent people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea and difficulty talking. If you suffer from social phobia, you may be painfully embarrassed by these symptoms and feel as though all eyes are focused on you.

You may be afraid of being with people other than your family.

People with social phobia are aware that their feelings are irrational.  Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout the event.  Afterward, the unpleasant feelings may linger as they worry about how they may have been judged or what others may have thought or observed about them.

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) is much more than the normal anxiety most of us experience occasionally in our daily lives. GAD emerges gradually and can begin at any time, although the risk is highest between childhood and middle age.

  • GAD is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems.

  • There is evidence that genes play a modest role in GAD.  GAD is commonly treated with medications.

GAD is usually accompanied by another anxiety disorder, depression or substance abuse. These other conditions must be treated along with GAD.

  • GAD is chronic and fills one's day with exaggerated worry and tension, anticipating disaster, often worrying excessively about health, money, family or work. Sometimes, simply the thought of getting through the day provokes anxiety.

  • GAD is often accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating and hot flashes. People with GAD may feel lightheaded or out of breath. They also may feel nauseated or have to go to the bathroom frequently.

  • Often, GAD sufferers have trouble falling or staying asleep.

Specific Phobia

A specific phobia is an intense fear of something that poses little or no actual danger but is perceived as very dangerous.

Some of the more common specific phobias are centered around:

  • closed-in places
  • heights
  • escalators
  • tunnels
  • highway driving
  • water
  • flying
  • dogs.

Specific phobias aren't just extreme fear; they are overwhelming fear of a specific thing.  For example, you may be able to fearlessly ski the world's tallest mountains, but be so fearful of closed-in places that you cannot use elevators or drive through a tunnel.

If the object of the fear is easy to avoid, people with specific phobias may not feel the need to seek treatment.  Nevertheless, they may make important career or personal decisions to avoid a certain situations, and if this avoidance is carried to extreme lengths, it can be disabling.



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Dr. Zabrin Inan, MD
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