|Anxiety||To Mental Health theme page|
1. Core Knowledge
2. Nice to Know
Anxiety disorders are common, with a lifetime prevalence perhaps reaching 25% of the population (Antony MM, Swinson RP. Ottawa, Canada: Health Canada, 1996). The World Health Organization undertook a 14-nation study of psychological problems and set the prevalence of generalized anxiety, defined by the ICD-10 criteria, at 7.9%; a further 1.1% had a panic disorder, and 1.5% suffered agoraphobia. Although common, anxiety is under-diagnosed in the general population; nearly half of the cases in the WHO study had not been recognized by their primary care physicians (Sartorius N et al. Br J Psychiatry 1996; 168(Suppl 30):38-43).
Daniel Smith gives a vivid portrayal of anxiety in his book Monkey Mind: A Memoir of Anxiety. (Simon & Schuster, 2012). Here are some excerpts from an interview with him on CBC radio (March 10, 2013).
"Anxiety involves a methodical spinning out of consequences: seeing things in their worst light, inflating them to horror movie proportions and ending in horrible consequences. Anxious thoughts seize you by the lapels and you worry about the risks to yourself. The anxiety seals you off and you begin attending only to yourself. And it is recursive: you become afraid of something and so focus on it, which makes you more frightened. This leads you to pay attention to more and more things that make you frightened – the vicious cycle of anxiety entombs you in yourself. While you are in that state you cannot see other people; you cannot love other people. Meanwhile you grieve that you are on a merry-go round of thoughts but cannot break out. Anxious thoughts are like cult leaders: they grab you and draw you in; they seem to be concerned for you and they are persuasive. It’s hard to question them."
It is important to recognize a distinction between psychological and medical models of anxiety. The medical approach is categorical; to receive a diagnosis of anxiety, a patient must meet specified criteria, as laid out, for example, in the DSM-IV. The categorical approach is practical and provides a basis for deciding whether or not to treat a patient. The underlying assumption is that there is a qualitative distinction between those who are well and those who are sick; although sickness can vary in severity, cases either do not lie on the same continuum as non-cases, or at least form a distinctive cluster at one end of a continuum. This conception is widely challenged, however. Psychologists take a dimensional approach that treats anxiety as a continuum of severity (or, in some models, a set of continua) with no intrinsic threshold. The arguments for a dimensional conception point out that there does not seem to be a bimodal distribution of scores representing well and sick groups; there also seems to be a continuum of impairments due to anxiety, with no threshold beyond which rising anxiety scores would indicate an anxiety disorder. Similarly, a dimensional model has been proposed in mental status testing, where there is a diagnostic dilemma of how to classify people who do not meet the criteria for dementia, but who are also not normal. Most of the anxiety scales we review provide intensity or severity scores that reflect an underlying dimensional model of anxiety.
3. Additional Information
Etiological theories of anxiety are diverse, but may be grouped into biological theories which emphasize the relevance of hormone levels, neurochemical patterns and genetics, versus cognitive-behavioral theories which argue that such biological changes may result from psychological reactions. A synthesis between these perspectives has also been proposed. Behavioral theorists tend to emphasize the relevance of parenting styles and early learning experiences that may foster a fear response and a sense of powerlessness. Cognitive theorists point out the relevance of beliefs and perceptions for the maintenance of anxiety reactions. Clark, for example, showed that panic attacks may be triggered by a misinterpretation of normal physical sensations as presaging a threat; a vicious circle involves a reaction of heightened anxiety which produces more physical sensations leading to more catastrophic interpretations, spiralling into a panic attack (Clark DM. Behav Res Ther 1986; 24:461-470). Biological theorists have tended to focus on the role of particular neurotransmitter systems in particular anxiety disorders; the noradrenergic system may be linked to panic disorder, while the serotonergic system appears relevant in obsessive-compulsive disorders and dopamine may be relevant in social phobia, for example (Antony MM, Swinson RP. Ottawa, Canada: Health Canada, 1996).
Anxiety has long been recognized but only relatively recently studied systematically. Fear was apparently portrayed in ancient Egyptian hieroglyphics, and the Roman orator Cicero distinguished between a character predisposition to anxiety (anxietas) and emotional responses to situations (angor). Nineteen hundred years later, Darwin analyzed the role of fear as an adaptive response involving common signs such as heart palpitations, dilation of the pupils and increased perspiration. Freud subsequently distinguished between objective and neurotic anxiety, based on whether the source of anxiety was external or internal. The feelings of apprehension, irritability and physiological arousal are the same in both conditions. Objective anxiety, synonymous with fear, is an internal reaction to a real external threat, while Freud characterized internal or neurotic anxiety as a reaction to the person’s own repressed sexual or aggressive impulses that threaten to enter consciousness. For Freud, neurotic anxiety arises especially in response to unacceptable impulses such as Oedipal conflicts or sexual feelings that may have been punished in childhood and are accordingly repressed. If a person’s repression of their impulses should partially break down, placing them in danger of re-experiencing repressed psychological trauma, they may experience a free-floating anxiety that appears to have no specific object save a fear of punishment if the inner impulses are expressed openly. Neurotic anxiety may be inferred when anxiety reactions appear disproportionate to the level of threat. Freud also described moral anxiety, in which the conflict lies between the person’s impulses or unconscious desires and external prohibitions as perceived through the person’s conscience. Thus, a high school student who is attracted to a teacher will feel anxious about meeting the teacher in the corridor.
A limitation of Freud’s theory is that it did not adequately distinguish among the resulting feelings of stress, guilt, anxiety or depression, which tended to be grouped under the general label of “neurotic” symptoms. Freud’s perspective was also strictly clinical and he opposed formal measurement; this orientation seemed to delay the development of anxiety scales for roughly 30 years.
The 1950s saw the development of an experimental tradition in studying anxiety. Laboratory studies assessed the links between personal drive, anxiety and the complexity of an experimental task, and feelings of fear and frustration. In 1953, Taylor presented her Manifest Anxiety Scale which built on Freud’s theme of neurotic anxiety. The scale was widely used in experimental research; common findings were that people with higher drive, or “manifest anxiety,” showed superior performance in simple response tasks, but less adequate performance in complex tasks that included many possible types of error. Anxiety came to be viewed more comprehensively as a process that involves stressful threats, personality characteristics and defences, and behavioral reactions.
During the 1960s, this reference to personality led to Spielberger’s empirical demonstration of a distinction between anxiety as a reaction, versus an underlying tendency to respond to threats. Cattell and others had applied newly developed multivariate analysis techniques to measures of anxiety, also showing two distinct facets of anxiety, state and trait, that were not included in Taylor’s measure (Spielberger CD. Southern Psychologist 1985; 2:6-16). Traits refer to enduring and general dispositions to react to situations in a consistent manner; trait anxiety involves a tendency to experience anxious symptoms in non-threatening situations; it implies vulnerability to stress. State anxiety is a discrete response to a specific threatening situation: Freud’s objective anxiety. State anxiety involves transitory unpleasant feelings of apprehension, tension, nervousness or worry, often accompanied by activation of the autonomic nervous system. It presumably forms a natural defence and adaptation mechanism in the face of threat. People with high trait anxiety are assumed to be more prone to experiencing state anxiety, perhaps to excess. Freud had anticipated this in his recognition of the variations in response to objective threats among normal and neurotic persons.
The distinction between anxiety and depression
"A Freudian slip is when you say one thing but mean your mother"