Addiction Treatment Blog

In addition to the types of anxiety mentioned earlier, there are a number of different situations in which anxiety arises according to which it is categorised and treatment given. There are many different occasions of anxiety and in this article, you will find a detailed explanation to each of them in different subjects; such as Stage Fright Anxiety, Panic Disorder, Obsessive Compulsive Disorder, Generalised Anxiety Disorder (GAD), etc.

Table of Contents

• Stage Fright Anxiety
• Neurotic Anxiety
• Phobic Neurosis
• Panic Disorder
• Social Phobia
• Obsessive Compulsive Disorder (OCD)
• Hysterical/Dissociative Disorders
• Health Anxiety/Hypochondriasis
• Generalised Anxiety Disorder (GAD)
• References
• Help

Stage-fright Anxiety

This is the kind of anxiety that many get when faced with an interview, or having to speak before a crowd or perform in some way for others. The typical manifestations of stage-fright are increased muscular tension, sweating, butterflies, a tremor in the hand and palpitations as well as a feeling, perhaps, of being unreal or out of touch. In other words, some aspects of all of the forms of anxiety mentioned above. Stage-fright can often be helped by either minor tranquillisers or beta-blockers.

The basis for a response to these drugs appears to lie partly in an interruption of the feedback from increased heart rate or muscular tension to mental state. Typically when we get anxious, our heart rate increases, our hands shake and we begin to perspire. This in turn leads us to be more anxious. If these signs of anxiety are blocked, we appear to assume that we are less anxious and as a result we become less anxious. In other words, we can trick ourselves into thinking that we are not as anxious as we actually may be by blocking the usual signs of anxiety. In certain circumstances this can be seen as a legitimate manoeuvre, and is undoubtedly what human beings have been doing for centuries, indeed millennia, mostly hitherto by using alcohol to abolish the manifestations of anxiety – giving us Dutch courage.

There are two potential problems with this procedure, however. One is that it is normal to feel anxious before a performance of any kind and, indeed a certain amount of anxiety possibly contributes to a good performance, helping one to a perform at a level higher than otherwise. People who are too relaxed and at ease lose a certain amount of ‘edge’. One pitfall, therefore, is that over-zealous tranquillisation may impair performance.

A further pitfall lies in starting the treatment of anxiety too early. In the case of a concert or a speech or an interview, treatments should only be used on the day of the performance or, at the most, to include the night before. The danger is that if performances come close together and an individual is self-medicating for too long before each performance, they will slide into a routine of constant medication. This may produce dependence in the case of drugs such as alcohol or benzodiazepines.

Another problem is that while it is probably legitimate to use drugs of this sort in an appropriate way, if they are found effective there is an inevitable tendency to rely on them rather than to develop the skills to help manage anxiety. This presents a dilemma in that a judicious use of anxiolytics to combat stage-fright may enable the person to go on stage and perform more readily and, thereby, potentially become more accustomed to the process and, as a consequence, less anxious about it. In other words, anxiolytic drugs can lead gradually, if used properly, to their own discontinuation.

This is, however, open to abuse. The best known case of such abuse in recent years has been the use of beta-blockers by snooker players to inhibit any tremor they may have in their hands, which would, of course, interfere with cueing. In this case, one also has to ask whether the anxiety is of the prospect of performing or losing. The latter would not be likely to clear up after using minor tranquillisers or beta-blockers for a short time, and is more likely, therefore, to lead to chronic self-medication.

Neurotic Anxiety

We all become acutely anxious on occasions. If the anxiety is intense, or long lasting, or if it catches us at vulnerable time, then there is a tendency for it to organise itself into neurosis. A neurosis is a relatively long lasting and self-perpetuating maladaptation to anxiety.

For example, someone who goes out and has a shock, while out shopping may perhaps be left nervous. They may then subsequently, when they come to go shopping next, find that they are apprehensive about going out. If they don’t go out to the shops, perhaps by getting one of the children or a neighbour to go instead, the likelihood is that a certain nervousness about going shopping will become established. Not going shopping in order to avoid becoming anxious leads progressively to an inability to go shopping, and to even more anxiety when one has to face to up to what it is that one has been avoiding. Such problems can be self-perpetuating.

Sometimes the difficulty may clear up spontaneously. Many neuroses also respond very favourably to behaviour therapies, which act on much the same principle as telling someone who has just fallen off a horse to get up and ride again as quickly as possible. Blocking avoidance responses and exposing oneself to the thing that one is afraid of are the basic behavioural methods for handling neurosis. They work extremely well and are broadly speaking the optimal therapy for phobic and obsessive-compulsive neuroses (1).

However, there are other treatments and anxiolytics that are commonly used for various neuroses. To understand their place we will first lay out the different kinds of neuroses and then indicate where and why drug treatments may also be employed.

Phobic Neurosis

There are both general and specific phobias. A general phobia, for example, is agoraphobia, the fear of being outside. Specific phobias relate to a particular thing, such as spiders, snakes or thunder and lightning.

Exposure therapy is the treatment of choice for a phobic disorder uncomplicated by a depressive illness. Antidepressants are also often used for agoraphobia, although they are rarely, if ever, used for the more specific phobias. One rationale for using antidepressants in these conditions is that many people who are agoraphobic will also have a concomitant depressive disorder and if this is tackled the neurosis may clear up. But, in addition to clearing up of a depressive disorder, the SSRIs and MAOI antidepressants appear to be independently anxiolytic, as there is some evidence that treatment with these drugs may be of benefit to those with phobic anxiety who are not depressed. Whether treatment in such a group should ever rely solely on drug treatment, without including a behavioural input also is a matter of some dispute.

Panic Disorder

Panic disorder is a state that can come on either in company, out of doors, or indoors at home alone. The experience of panic usually seems intensely physical to the affected individual. They become aware of their heart thumping and hands shaking. They may have feelings of nausea and feel weak and short of breath. They may also have feelings of impending doom. Panic disorders typically come out of the blue, and may lead secondarily to a phobia of going shopping if, for example, the first panic attack happens in the supermarket – afflicted individuals are then often understandably nervous about going to supermarkets again (2).

There have been vigorous attempts to market a number of antidepressants and anxiolytics, particularly the minor tranquilliser, alprazolam, for panic disorder. Most of the antidepressants, both the tricyclics, the MAOIs and more recently the SSRIs have been tested in clinical trials for panic disorder, and have been shown to have a certain amount of usefulness.

Exposure therapy is used widely to manage panic disorder as well as a recently developed variation of cognitive therapy (3). Briefly, the behavioural and cognitive approaches propose that people who panic experience the symptoms of anxiety, such as increased heart rate, breathlessness, feelings of weakness and palpitations, and interpret these in terms of an imminent stroke, loss of control, heart attack or outburst of some sort. They then take evasive action to avoid such things. Typically, a person who fears a heart attack will, for example, sit down just as any reasonable person who actually thought they were having a heart attack would do. This sitting down and taking things easier, however, perpetuates the problem. Treatment aims to get the person to do the opposite to what they have been doing and to try and get hold of the thoughts that come to their mind during episodes of panic, so they can recognise what is happening. Over and above this, the cognitive approaches further emphasise the thinking style of affected individuals.

Social Phobia

Three forms of social phobia are described. A specific form which involves having to perform in front of others, a degree of stage-fright sufficient to lead to avoidance. A generalised form that involves avoidance of most occasions of interaction with others from shopping because of difficulties in asking for things, to avoiding the bank teller and using automated tellers instead, to crossing the street when aware of the approach of anyone who might want to stop and engage in conversation. The difficulty with this phobia is extreme self-consciousness; the individual is constantly self-evaluating and feels that he is boring. Finally, there is a condition termed avoidant personality disorder which, as the name implies, is a state where the individual’s freedom to act is heavily constrained by their interpersonal difficulties. In its extreme form, individuals with this condition may become house-bound. There is a high incidence of alcohol abuse and co-occurrence with other phobic disorders, panic disorder and depression.

Until recently, social phobia was all but unrecognised in the West, although it is commonly diagnosed in the East. The condition is still likely to be viewed by suferers and others as a form of shyness, not as something which would lead to the seeking of medical help. Accordingly, it neither presents in primary care nor is detected by primary care  physicians, despite estimates that up to 3% of the population may be affected (4). There are a number of programmes in place to increase recognition, as the condition may lead those affected to be unable to sustain a relationship or hold down employment.

Clinical trials have recently shown that the RIMA and SSRI antidepressants may bring about some improvement in the condition and may do so for individuals with severer forms of the disorder, even in the absence of any obvious concomitant depressive disorder. In contrast, beta-blockers or benzodiazepines appear to be of limited usefulness. A number of behavioural and cognitive strategies are also emerging and, as with the phobic disorders, it would seem that the best management in future will probably involve an appropriate combination of pharmacotherapy and behavioural approaches.

Obsessive Compulsive Disorder (OCD) (5-6-7)

There are three fairly dissimilar behaviours that may be subsumed under this title. First is a general indecisiveness and inability to take action. Second is an obsessional and ritualised checking on things, such as whether one’s hands are clean, or whether one has locked the back door, turned of the gas, etc., things we all do but which may be done in OCD to an extraordinary and disabling degree. The third is having images or urges present themselves to one’s mind and being fearful that one will give into them. Examples include images of oneself shouting obscenities in public, or impulses to pick up a knife and skewer the children. The fear that such imagery or impulses may generate can be extreme.

In recent years, there have been many claims that antidepressants with 5-HT reuptake inhibiting properties can be useful for individuals with OCD. The drug for which most research has been done, and for which most claims have been made has been clomipramine (Anafranil). But there is now clinical trial evidence that each of the SSRIs may be useful in OCD. However, if there is agreement about what exactly it is that they do – are they anxiolytic in some way or antidepressant – and just how useful are they. This will be developed at a later stage.

As with the other neuroses, one good reason fur using an antidepressant in OCD is that very often there will be an underlying depressive disorder, the stress of which has precipitated the full-blown neurosis. Resolution of the underlying depression may bring an improvement of the neurosis or make the person more accessible to a behavioural programme. This, however, might be expected to be true for any antidepressant, and not just for anti depressants with 5-HT reuptake inhibiting properties.

Is the usefulness of the SSRIs in OCD then down to some anxiolytic effect of 5-HT reuptake inhibition, or are these drugs in some way specifically anti-obsessional (8)? In favour of the idea that the SSRIs help because they are non-specifically anxiolytic is the fact that these drugs also seem useful in panic disorder, social phobia and other anxiety states. This raises the question of whether any other anxiolytics may also be useful for obsessive compulsive disorders. The simple answer to this is that we don’t know. No proper clinical trials have been done on any other agents. It seems unlikely that beta-blockers or benzodiazepines would be particularly useful as there are no prominent physical symptoms of anxiety in obsessive compulsive disorder.

However, there very often is a marked degree of agitation and on this basis one might imagine that neuroleptics would be useful. Before the recent vogue for using SSRIs, neuroleptics were indeed used quite widely and successfully for some people who had OCD. The recent literature suggests that neuroleptics may be particularly useful when the clinical picture contains tics or other features of Tourette disorder.

The main form of treatment, however, for OCD is behavioural management. This goes both for the ritualistic and the intrusive imagery and impulse types of OCD. Behaviour therapy is much less successful it would seem for obsessive compulsive disorders that are characterised almost solely by indecisiveness or slowness. The principle behind a behavioural approach in these disorder is to expose the sufferer to the thing that is frightening them most and to block, at least temporarily, their avoidance of what they have been avoiding. This forces the individual to encounter the stimulus to their fears and habituate to it. Such an approach may produce a brief spell of intense anxiety, but it appears to be an effective way of breaking obsessive compulsive cycles of behaviour.

Hysterical / Dissociative Disorders (9)

At one point, a diagnosis of hysteria was the commonest diagnosis in medical circles for patients who had any kind of trouble with their nerves, or psychological disorder of any sort. It has fallen out a favour for a variety of reasons. It has fallen out a favour for a variety of reason. It remains the case, however, that there are a number of patients who will have classic hysterical neuroses, where they seemingly become paralysed in a leg or an arm, for instance, or go blind in an eye without there being any apparent physical basis for the problem. Ordinarily this will be triggered by some sort of psychological shock or ongoing stress.

While there are unquestionably a number of such cases that happen without the affected individual also being depressed, it is common to find at least mild degrees of hysteria in many patients who are depressed. The reverse is also true, in that it is quite rare to find people who have hysteria who are not depressed. Very often effective treatment of an underlying depression will help clear up a hysterical neurosis. One of the mechanisms by which patients who are depressed become hysterical is something like the following. People who are depressed may have clear problems concentrating, or in trying to remember things, which might be caused by the physical changes in their brains brought about by depression. Given that being anxious about remembering may itself interfere with being able to remember, someone who is both depressed and anxious may conclude that they have Alzheimer’s disease, or something similar, and start behaving accordingly. Both depression and anxiety produce a range of other physical and psychological symptoms that may crystallise out in a similar fashion.

Today, there is a certain swing back towards a diagnosis of hysteria, but typically the condition is called a dissociative disorder rather than hysteria. Simply put, dissociation means that psychological functioning is in some way split by pressure or stress. For example, the idea of how to use your arm is cut off from the actual arm itself so that, while there may be nothing wrong with your arm, you may not be able to use it – it may be effectively paralysed. Under strain or stress, people may often be cut off from memories of things that happened in the past, even so profoundly cut off as to be unable to remember their own name, or how they got to where they are. This is not uncommon in people before interviews or exams.

At the turn of the century, Sigmund Freud, Pierre Janet and others argued that hysteria more often than not arose in response to trauma. Many of the features of hysteria as they described it then correspond well with what is now termed post-traumatic stress disorder (PTSD), which came into being officially in 1980, and is a condition that comes on after trauma, whether rape, physical violence, sustained mental torture or disaster of one sort or another. These are thought to precipitate a dissociation or split within the individual, so that they are in part cut off from what happened them. Their feelings or experiences subsequently are of recurrent intrusive images of what has happened to them but which they cannot clearly remember, or uncertainties regarding things they feel they ought to have done during the traumatic episode, such as struggle more in the course of a rape. These alternate with episodes of numbness, blankness and amnesia. There may be a pervasive feeling of unreality and a generalised anxiety with an increased liability to be startled.

There is, at present, no effective pharmacological treatment for this disorder. If caught soon after the initial trauma, tranquillisation with benzodiazepines or barbiturates may help. Quite commonly, people who have a post traumatic stress disorder also develop a depressive disorder at points during the course of their post-traumatic state. Antidepressants, in this case, may be helpful for the depressive component to the picture.

Post-traumatic stress disorder has only recently been recognised and a number of attempts have been made to try and produce techniques to manage the recurrent intrusive images and episodes of emotion that happens in this disorder. Such developments are at present at an early stage. At present the condition seems more likely to resolve (at least temporarily) if the subject can actively engage in doing new things and getting on with life.

When the condition has become chronic, it is common to find that sufferers resort to alcohol or minor tranquillisers to numb the distress they feel. While these may very effectively numb in the short term and may even in the short term assist in the resolution of the disorder, neither works well in the long term. Where the disorder is long lasting, and characterised by recurrent intrusive memories and flashbacks or nightmares, there is some evidence that drugs active on the 5-HT system may help.

There is a variation of post-traumatic stress disorder called a borderline disorder, or borderline personality organisation. Present research suggests that the condition results from chronic trauma during childhood. This leads to recurrent dissociative experiences with unstable interpersonal relationships and self-injurious episodes. One hundred years ago this condition would also have been called hysteria. In recent years, individuals with this disorder have been more likely to be diagnosed as having schizophrenia.

Antidepressants may sometimes be of use in these states. But very commonly, far from helping these states, antidepressants aggravate the depersonalisation and derealization to which such individuals are prone. Neuroleptics may help to reduce the impulsive behaviour, such as self-mutilation, that often goes with the condition. However, benzodiazepines appear to be the most reliable means of bringing the acute episodes of dissociation or extreme agitation that accompanies this disorder to an end.

Health Anxiety / Hypochondriasis (10)

There seems to be a widespread tendency to rename conditions, when an older name conjures up pejorative associations. Often the renaming appears to lose something of the resonance of the older term. Recently, the condition of hypochondriasis has been subject to this process and has become health anxiety, a term which, in this instance, indicates far more clearly what this condition is all about.

As has been pointed out both depression and anxiety may give rise to a range of physical sensations, some of which may be extremely uncomfortable and which may give the impression that there is something physically wrong. Consulting a text book on the sensations of weakness and tingling feelings, such as may come about as a result of anxious hyperventilation, would lead many of us to give ourselves a diagnosis of something like multiple sclerosis, for example.

It may be difficult to shift an individual from such a diagnosis, as symptoms of multiple sclerosis are non-specific and often, if it is an ongoing anxiety, it may well appear that they physical sensations being experienced map fairly well onto the diagnosis worked out from a text book. Besides which, the medical profession has a reputation for not telling anybody when they have got something seriously wrong with them such as cancer, schizophrenia or multiple sclerosis. Accordingly, the fact that your doctor does not confirm the diagnosis you’ve come to yourself may for many people not be very reassuring.

There are a number of other factors that may play a part in the generation of a health neurosis. One is that attention to a physical complaint is all too likely to either aggravate that complaint, or at least give it a salience that then becomes difficult to ignore. Such attention may have a defensive quality to it. When any of us are anxious or under stress, one defence mechanism for coping with the problem we are faced with is what is termed a displacement reaction. This is what happens when, for example, we have to study for an exam or write an awkward letter, and somehow it seems there are a whole range of other things that seem easier to do – tidying the pens in their holder, clearing out the drawer in the desk, etc. In the same way, displacement on to what might appear to be a physical problem may lead to an ongoing awareness of that aspect of health functioning, long after the original stress has been resolved.

An unhelpful focus on aspects of health is more likely in someone who has particular ideas about their health. Thus someone who believes that their bowels must move at least once a day, and that there are serious consequences for their health if they do not, may get very preoccupied by the constipation that often goes with depression. In the future, we will argue that in many respects, chronic insomnia can be viewed as a form of health anxiety. Fixed ideas about health, such as the need for daily bowel movements, or for a regular 8-hour sleep, tend to run in families.

Far from being a mild disorder, health anxiety will often lead to repeated visits to general practitioners, alternative therapists and a range of other ‘healers’. The disorder can become extreme, with an individual becoming paralysed by their fear of interfering with the physical condition they are afraid they may have. They may even, for example, get to the state of urgently calling in the police to bring them to hospital as they are sure something terrible is happening. Repeated physical investigations rarely yield anything of note. The complaints of ill health are often incessant, so that family members, general practitioners and others become either very irritated or very concerned.

At present a number of cognitive therapy strategies for health anxiety are being developed that resemble those in use for panic disorder (both conditions involve a misinterpretation of physical symptoms). Behaviour therapies have not been as effective as in obsessive or phobic disorders. A general anxiety management strategy may help, particularly if there is any evidence that some of the symptoms come on after episodes or hyperventilation.

On the basis that health anxieties often become established in someone who is depressed, treatment with an antidepressant is common, if there is any hint that the individual concerned has an underlying depressive disorder. The hope is that treating the depression will lead to a resolution of the neurosis.

Generalised Anxiety Disorder (GAD) (11)

In theory, defining feature of this disorder is unrealistic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances, e.g. worry about possible misfortune to one’s child (who is in no danger) and worry about finances (for no good reason), for 6 months or longer. During this time, a person must be bothered by these concerns more days than not. This condition may affect children and adolescents, taking the form of anxiety and worry about academic athletic and social performance. When this person is anxious, there should be signs of motor tension, of autonomic hyperactivity and of increased vigilance and arousal.

The symptoms of motor tension include: trembling, twitching, or feeling shaky; muscle tension and aches or soreness; restlessness; and easy fatigability. Those of autonomic hyperactivity include: shortness of breath or smothering sensations; palpitations or accelerated heart rate, sweating, or cold clammy hands, dry mouth, dizziness or light-headedness; nausea, diarrhoea, or other abdominal distress; hot flushes or chills; frequent urination; and trouble swallowing or a ‘lump in the throat’. The symptoms of increased vigilance and arousal include: feeling keyed up or on edge; exaggerated startle response; difficulty concentrating or finding one’s mind going blank because of anxiety; trouble falling asleep; and irritability.

In diagnosing the disorder, other disorders that are frequently associated with generalised anxiety need to be ruled out. Thus, the diagnosis is not made if the worry and anxiety are only present when the person is depressed. In practice there is considerable overlap between GAD and the other neuroses both as regards symptomatology and the fact that many individuals may present with what appears like a phobic neurosis one year, GAD the next and perhaps OCD the following year. If one of the worries is about health, then distinguishing GAD from health anxiety may be very difficult.

Broadly speaking, GAD refers to the large number of anxious states, in which individuals appear globally or diffusely anxious, in which there has been no crystallisation of the anxiety into a clear phobic or obsessive state, or preoccupation with health as the sole focus of concern. For these reasons, it may be difficult to see a point of entry for cognitive or behavioural strategies. GAD, therefore, is the anxiety state state for which general practitioners and others have tended to resort to the use of minor tranquillisers, and for which they have been blamed for an inappropriate tranquillisation of distress. They are now being encouraged to use antidepressants, particularly SSRIs, on the basis that these drugs do not produce dependence, are anxiolytic and that behind a GAD there may often be a depressive disorder.

The typical picture of a generalised anxiety disorder is of a person who has multiple problems on their plate and who is, in many respects, legitimately anxious. The problem lies in the maladaptive or habitual nature of the anxiety or in its severity. Very often the problems may be relatively intractable and, out of ’sympathy’, a doctor will prescribe something to try and calm the person down or take the edge of their distress. This may lead when the pills fail to work, to an increased level of prescription or to the addition of yet other drugs into the cocktail. The person in question has their distress dulled but often at a cost.

When not diablingly severe, GAD is the form of anxiety that lends itself most readily to interpretative approaches. These may include an identification of the real stresses that the individual may be under, such as an unhappy marriage, isolation in a suburban housing estate or in a tower block, cut off from other family members, or pressures at work stemming perhaps from a downturn in the general state of the economy. The identification of such stresses and the institution of appropriate anxiety management strategies may be all that is needed to bring about considerable change.

References

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