Why is the Prevalence of Anxiety Disorders a Concern?
I have chosen anxiety disorders to be one of my areas of expertise of clinical practice, because it is one of the most common mental health disorders. Anxiety is an emotional response to current events and/or a fear of negative outcomes of future events. Along with the emotional symptoms of anxiety and fear, anxiety disorders are characterized by worried thoughts and physical symptoms including: fast heart rate, shortness of breath, and shakiness. It affects approximately 40 million adults in the United States, who are 18 years or older, which is 18% of the population.
One in four adults will have an anxiety disorder at least once in their lifetime, and one out of 10 adults will have an anxiety disorder each year. Most people with anxiety disorders have reoccurrences of symptoms periodically, particularly when triggered by every day stressors, or a traumatic event. Although not the only variable or cause, many of today’s economic and social pressures contribute to the incidences of anxiety symptoms and the diagnoses of neuroses. I find it surprising that in our great nation of healthcare more attention is not given to anxiety disorders, as people with these diagnoses are three to five times more likely to see a doctor, and six times more likely to be hospitalized than other individuals (DSM-5, 2013).
If Anxiety Disorders are so Common, Why Don’t More People Go to Counseling?
Although it is highly treatable with positive outcomes, only 36.9% of those having symptoms participate in counseling interventions (DSM-5, 2013). If more attention was given to the knowledge and treatment of anxiety disorders, people with symptoms would likely feel less shame about having it, and likely would seek the counseling they need; more importantly, they would have better and happier lives. Often, people think that they will be treated differently or be labeled as “crazy” if they have a mental condition. The truth is that no one is at fault for being anxious or depressed. Recovery and being symptom-free has nothing to do with willpower, weakness, immorality, or competence. Most people have sought some type of counselling in their life, and some more than once. Being diagnosed with a mental health disorder/condition does not mean that someone cannot be functional, socially respected, and/or a successful person, if the proper professional help is received.
Most of my clients with anxiety disorders originally believe that the feeling of anxiety is abnormal. However, anxiety can be a healthy emotion when it is felt in low to moderate levels, and some people who have low to moderate levels of anxiety symptoms do not seek or need counseling.
As a matter of fact, it can be healthy and a normal response to dangerous situations. When something happens that could or has hurt someone, it can drive them into action and correct or divert a problem or situation. As an example, if someone is concerned that their bills cannot be paid timely, and they may lose their residence, they may become anxious and worried, resulting in working more hours to meet their financial obligations. If I see a car heading toward me, the anxiety I feel will cause me to drive faster and I will veer off the road to assist in my personal safety.
When Do Worry and Fear Become Characteristic of an Anxiety Disorder?
I find that the distinction between normal anxiety and an official diagnosis of an anxiety disorder is not always clear, particularly at the onset or in its early stages. I notice that anxiety and fear become problematic when incidents or episodes of anxiety increase in chronicity or severity, frequency, number of symptoms, and/or duration of time or episode. I make a diagnosis of an anxiety disorder when symptoms become a problem and affect health, work, family, and/or social interactions. Anxiety can cause health conditions, hinder concentration and memory needed to fulfill family obligations or employment tasks, and lead to irritability or impulsiveness, that can negatively affect relationships.
I usually notice different physical, emotional, cognitive, and behavioral symptoms when clients verbalize their anxiety symptoms. Anxiety has been described by its many physical symptoms, which include: racing heart, high blood pressure, fast or difficulty breathing, shortness of breath, headaches, chills, sweats, trembling or shaking, numbness, dizziness, feeling faint, and/or muscle tension. It can include digestive problems or stomach aches, indigestion, irritable bowel syndrome, and/or ulcers. These physical symptoms usually occur simultaneously with worried thoughts and emotions of nervousness, overwhelming fear, restlessness, and agitation. Distorted thoughts or irrational fears are the contributing factors to the emotional and physical symptoms of anxiety. These include: excessive worrying or preoccupations about certain situations, worrying about most things most of the time, thinking of many things at once, and/or racing thoughts. It is a preoccupation with unrealistic anticipation of negative outcomes. Other cognitive problems such as the inability to focus or concentrate, and memory deficits can occur. Behavioral symptoms may include nonstop talking, pacing, fidgeting, and/or nail biting. Anxious people avoid situations that make them feel unsafe and trigger fear and anxiety, (DSM-5, 2013).
What Mental Health Disorders are Characteristic of Anxiety Disorders?
Although there are different types of mental health disorders that have components and symptoms of anxiety disorders, there are seven main disorders that I treat in my clinical practice: Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, Panic Disorder, Agoraphobia, Specific Phobias, Obsessive Compulsive Disorder (OCD), and Post Traumatic Stress Disorder (PTSD). (Rauch, 2017). (DSM-5, 2013; Rauch, 2017).
- Generalized Anxiety Disorder (GAD): My clients with this anxiety disorder consistently have anxious thoughts about many things, on most days of the week, for a duration of at least six months. The anxiety may not be a response to a specific thing or situation. Although there is may be no reason for the uncontrollable anxiety, they have invalid thoughts that something terrible is going to happen to them.
- Social Anxiety Disorder: My clients with this anxiety disorder have excessive anxiety about being judged or disapproved by others in social situations for no reason (sometimes referred to as performance anxiety) and difficulty meeting new people (particularly in new places). From client reports, embarrassment or feeling humiliated is described, and their peers describe the them as being shy. These anxiety symptoms inhibit social interaction and hinder future relationships.
- Panic Disorder: My clients with this anxiety disorder have sudden intense anxiety and have a pattern of panic attacks that are perceived to occur randomly for no reason. Along with the present anxiety symptoms, they have significant fear that a very unpleasant panic attack will happen again in the future.
- Agoraphobia: My clients with this anxiety disorder have extreme anxiety, fear, and avoidance of being in open or closed public spaces, such as crowds, public transportation, or standing in line. Those situations trigger feelings of panic, helplessness, embarrassment, and being trapped. Some clients with agoraphobia also have panic attacks.
- Specific Phobias: Although there have been no past negative experiences, my clients with specific phobias avoid certain types of objects, places, and/or situations because fear develops suddenly, when danger is anticipated and they are exposed to the specific object/situation/place. I find that phobias may start from trauma associated with the object/situation/place, but it usually develops by just the mere suggestion or negative thought about the object/situation/place and continued avoidance can reinforce anxiety and/or worsen the phobia. A phobic client may avoid a situation just because he/she has heard negative interpretations of a situation by trusted others, and continually avoid it as the fear escalates over time.
- Illness Anxiety Disorder (Hypochondria, Health Anxiety Disorder): My clients with this anxiety disorder have unrealistic and excessive anxiety of becoming sick. I have observed that even minor physical symptoms and sensations are interpreted as major diseases or conditions that interrupt daily functioning and/or cause imaginary pain.
- Obsessive-Compulsive Disorder (OCD): My clients with OCD have uncontrollable and excessively repetitive, recurring thoughts (obsessions) and behaviors (compulsions). Their anxiety results from distorted thoughts of something not being right or perfect and causes feelings of disgust rather than feelings of pending disaster. I have witnessed that the repetitious, corrective behavior only temporarily pacifies the associated irrational thoughts (i.e., a client who stops washing his hands will return to the behavior when his irrational thought of uncleanliness reoccurs).
- Post-Traumatic Stress Disorder (PTSD): My clients with PTSD have intense anxiety triggered by visual, auditory and other sensory stimuli usually associated with a past traumatic experience that threatened their own safety or the safety of others. Traumatic events such as being physically assaulted or watching someone die in an accident have caused other symptoms of flashbacks, nightmares and intrusive memories.
Causes and Contributors of Anxiety Disorders
From my clinical experience with clients, anxiety disorders develop from different risk factors that include genetics, brain chemistry, personality, and learned negative experiences. As anxiety disorders can develop due to biological, social, and environmental reasons, and each client is unique, it is unclear if the cause is due more to internal biological (nature) or external environmental (nurture) factors. It would depend on the specific anxiety disorder and the individual client. Biologically, it can be a result of family genetics, an imbalance in brain chemistry, and/or innate personality characteristics. Like many psychological illnesses, anxiety disorders have genetic factors in which conditions or traits are passed down from one generation to another. If you know you have an anxiety disorder and have access to your family medical history, most likely one or more blood relatives have had an anxiety disorder. However, I have found that my clients with an anxiety disorder may not have the same type of anxiety disorder as the family member who also has been diagnosed with an anxiety disorder.
There is significant research suggesting that there are biological factors and chemical imbalances in the brain that cause different types of anxiety disorders. “There is convincing evidence for associations between anxiety disorders and several neurotransmitter systems, including excitatory amino acid glutamate, inhibitory amino acid γ-aminobutyric acid, and other neurotransmitters and neurochemical compounds such as catecholamines, benzodiazepines, serotonin, cholecystokinin, corticotropin-releasing hormone, and somatostatin.” (Grachery, I.D. & Apkarien, A.V., 2000).
Anxiety disorders can also be related to negative past experiences where people have learned that a certain object, people, place, or situation can hurt them or others. People who have past negative childhood experiences of verbal or physical abuse are more likely to develop anxiety and fears. If a child saw his/her father die in a home fire, he/she may develop a fear of fire as well as anxiety about losing loved ones in the future. Present and current stressors such as health problems, employment demands, financial burdens, and family obligations can cause or exacerbate anxiety symptoms. I have noticed that the chronicity of anxiety symptoms depends on the severity of the stressor, the time duration between different stress events, the number of stressors occurring at once, and if the stress events(s) was/were expected. Anxiety is heightened with more frequency, duration, and chronicity of stressful events.
I have noticed that stressful events causing major change can be more stressful than ones that do not require behavioral adjustments. Although developmental events (such as marriage, childbirth, employment promotion/advancements) are positive changes, they can also be stressful because the transitional change adds additional responsibilities and demands. Regardless if an event or change is positive or negative, I have concluded that stress is less severe if there are resources and support available to ease the symptoms of anxiety.
Counseling Modalities for Anxiety Disorders
Although I primary utilize Cognitive Behavioral Therapy (CBT) and Dialectic Brief Therapy (DBT) as modalities when I counsel my clients with anxiety disorders, I start with motivational enhancement techniques, upon evaluation, to determine the extent of how anxiety symptoms are affecting the client’s life, why they need to reduce the symptoms, and the benefits of eliminating the symptoms. This aids in goal development and measuring outcomes after implemented interventions. The evaluation includes inquiry into the frequency, duration, and severity of physical, emotional, cognitive, and behavioral symptoms. With the CBT approach, I explore how the feelings of anxiety are connected to negative self-statements and thoughts, and to physical symptoms and behaviors. The feelings of anxiety and associated behavior are reduced by changing a thought, behavior, or physical symptom. Changing one factor will change another, breaking the cognitive-behavioral pattern that perpetuates the symptoms. The CBT methods of breathing and relaxation exercises aid the client in eliminating the physical symptoms of racing heart, shortness of breath, and muscle tension. This in turn can reduce the racing thoughts and increase feelings of calmness.
DBT methods such as mindfulness and stress tolerance are also behavioral interventions that aid in coping with (stress tolerance) or changing (emotional regulation) negative thoughts into positive thoughts by focusing on pleasant, sensory experiences in the present rather than worried thoughts of the future. Sometimes it is helpful to use psychodynamic methods to examine how past negative experiences in childhood contributed to the development of an anxiety disorder. The modality and counseling intervention used is dependent on the type, severity, and cause of the anxiety disorder.
Diagnostic and Statistical Manual of Mental Disorders, Facts and Statistics. (2013). American Psychiatric Association, Fifth Edition. Retrieved from https://adaa.org/about-adaa/press-room/facts-statistics.
Grachery, I.D. & Apkarien, A.V. (2000). Anxiety in Healthy Humans is Associated with Orbital Frontal Chemistry, Molecular Psychiatry, Volume 5. Pages 482–488.
Rauch, Joseph. (2017). Different Types of Anxiety Disorders: How are they Classified? Retrieved from https://www.talkspace.com/blog/2017/05/different-types-anxiety-disorders-classified/