Anxiety Disorders
Anxiety Disorders are contained in diagnostic categories OF: (1) Panic Disorder without Agoraphobia; (2) Panic Disorder with Agoraphobia; (3) Agoraphobia without history of Panic Disorder; (4) Specific Phobia; (5) Social Phobia; (6) Obsessive-Compulsive Disorder; (7) Post-traumatic Stress Disorder; (8) Acute Stress Disorder; (9) Generalized Anxiety Disorder; (10) Anxiety Disorder due to a General Medical Condition; (11) Substance-Induced Anxiety Disorder; (12) and Anxiety Disorder Not Otherwise Specified. Obviously, there are twelve (12) diagnostic categories for Anxiety Disorders.
Panic Attack
A Panic Attack involves a rapid onset of intense apprehension, fear or even terror without exposure to extreme or unusual danger and is often associated with feelings of impending doom and an urge to escape. A panic attack can be a response to a mildly stressful situation or to no visible cause at all. Symptoms include: Difficulty in breathing, shortness of breath, dizziness or faintness, a rapid heartbeat, chest pain or discomfort, depersonalization, choking or smothering sensations, pain or shaking or trembling, sweating, nausea or diarrhea, numbness or tingling, chills or hot flashes, hyperventilation, a fear of going crazy or losing control, fear of dying and parethesis (a sensation as of numbness, tingling, prickling or creeping on the skin, without objective cause).
Panic attacks can occur in a variety of Anxiety Disorders (e.q., Specific Phobias, Post traumatic Stress Disorder, Acute Stress Disorder, Social Phobia, Panic Disorder). Panic Attacks can occur in three (3) types of situations: (1) The unexpected panic attack, in which the attack is not triggered by anything in particular, that is it is not associated with any stimulus. (2) The situaltionally bound panic attack, in which a panic attack occurs to the immediate exposure to, or the anticipation of the situation (e.g., seeing a spider or snake triggers a panic attack. (3) Situationally predisposed panic attack, in which the attack occurs on exposure to the cue or stimulus, and may not occur immediately after exposure (e.g., a person is attacked by a barking dog and a panic attack occurs one (1) hour after). The criteria for a panic attack is a period of intense fear, manifested by four (4) or more of the following symptoms within a period of ten (10) minutes:
1. Trembling or Shaking
2. Tachycardia or rapid heartbeat
3. Perspiration
4. Stomach upset or nausea
5. Heaviness or pain in the chest
6. Difficulty breathing or shortness of breath
7. Cold chills or hot flashes
8. Difficulty swallowing or choking
9. Feeling dizzy or fainting
10. Feeling as though you are dying
11. Feeling as though you are going crazy or not in control
12. Feeling as though things do not feel real or depersonalization
13. Parethesia, or heavy sensations of tingling, prickling or creeping of the skin
Agoraphobia
Agoraphobia is another form of an anxiety disorder, which occurs in the context of a panic attack or Panic Disorder with Agoraphobia and Agoraphobia without history of Panic Disorder. Agoraphobia is an anxiety in which the avoidance of places or situations may occur where the person is alone or feels alone without help when having a panic attack. The major concern with the agoraphobia is that should a panic attack occur, in certain places or situations, there is no one to help. This situation may express itself in an embarrassing situation or being away from home, for example, in a large open shopping mall, especially during Christmas, with crowds of people, or being in wide open spaces with no one around, as being in a desert or open plains. The agoraphobic fears being in situations away from home, or being in crowded places, such as a bus or train terminal with many people or driving through open places in the wilderness or desert. Furthermore, the agoraphobic will avoid certain situations, such as driving, flying, travel, and will attempt to tolerate the hardship with agonizing anxiety, fearing the panic-attack like symptoms. Often the agoraphobic will not be able to function with the presence of a companion, when leaving the home or driving the car.
It should not be confused that agoraphobia is not defined as another mental disorder, such as a person may experience Social Phobia, in which the individual becomes nervous and anxious in social situation being quite concerned with what kind of impression he or she is making on the other person or stranger in social situations. Accompanying these concerns are low-self esteem, low-self worth and a lack of confidence and embarrassment. Furthermore, agoraphobia should not be defined as a specific phobia, which is anxiety provoked by an exposure to a feared object or situation manifested by avoidance behavior, such as a fear of snakes, or bees. Another diagnosis that should not be confused with agoraphobia is Obsessive-Compulsive Disorder, such as a person who returns several or more times to check to see if the front door is locked, or avoids the fear of contamination by ritualistic hand washing, fifty or more times per day. And, we should not confuse agoraphobia with the diagnosis of Post-Traumatic Stress Disorder (PTSD), which an individual may have had a near life-death experience or stressor occur. For example, a sheriff is stopped at a red light in a Colorado town, is rear ended by another vehicle speeding sixty (60) miles per hour. The sheriff sustains severe herniated spinal injuries, having to live with severe pain. When driving on the freeway he comes to a near stop in his truck and hears tires screeching, as experienced that Sunday morning when he was rear ended. His reaction on the freeway, hearing tires skidding, precipitated a severe panic attack, in which he literally, jumped one (1) foot in his seat. In PTSD, the individual avoids stimuli associated with the stressor. Finally, agoraphobia should not be confused with Separation Anxiety Disorder, in which pre-schooler or adolescent before age 18 years, experiences, excessive anxiety with separation from the home or from e.g., a parent being away or absent from the child. Frequent crying spells may continue with long duration until the parents return, perhaps lasting days or even weeks.
Specific Phobia
A Specific Phobia is classified under Anxiety Disorders in The Diagnostic and Statistic Manual of Mental Disorders (DSM- IV). It is characterized by a clinical anxiety in which the individual will avoid exposure to a feared object or situation. An example is that an individual might have a fear of snakes or dogs and avoid this in a persistent fear of objects or situations. Any exposure will precipitate immediate anxiety or panic. In addition to the fear and avoidance, anticipation of the phobic stimulus can interfere with the person’s daily routine, social life and work function. This fear can be very intense, unreasonable and persistent. The anxiety is almost always experienced upon the immediate exposure to the feared object or situation. The level of fear is a function of proximity to the feared object or situation, and the level of escape, that is possible or impossible. It should be noted that, if the fear is reasonable and realistic, such as being hit by a car, when crossing a busy highway without pedestrian crossing, this diagnosis should not be given. The severity and types of different fears tend to increase with age, especially when untreated.
Specific Phobias have five (5) subtypes:
1. Animal Type – This subtype is triggered by a fear of animals or insects, in which the onset of the fear began in childhood.
2. Natural Environment Type – This subtype is triggered by a fear of nature and natural events, such as thunder, lightning, high elevations, in which the onset of the fear began in childhood.
3. Blood – Injection – Injury Type – This subtype is triggered by fear of an injury, blood, or injection or any other medical or dental procedure.
4. Situational Type – This subtype is triggered by fear of flying, driving on the freeway, being on a boat in water, or being in enclosed places.
5. Other Type – This subtype is triggered by a fear of situations that might lead too contracting the flu, falling down on stairs, not having a banister to hold onto. The most frequent subtypes to the least frequent are: Situational, Natural Environment, Blood-Injection-Injury and Animal. Specific Phobias often result interfere with social, recreational, occupational and intellectual functions in life. For example, an individual may not be able to take a vacation or travel to a particular place because of a fear of flying, or a person is unable to shop at a department store or enter a building to reach a higher floor because of a fear of riding in elevators. Certain medical conditions may increase with risk because of the phobic avoidance because of the individual avoiding medical care, as in specific phobias of Blood-Injection-Injury Type relating to dental or medical treatment because of the individual avoiding medical or dental care.
The question of what causes Specific Phobias are often founded in traumatic events (for example, being stung by a bee or several bees or being bitten by a dog).Other predisposing stimuli may include the observation of people experiencing some traumatic event or being in a panic state (such as people jumping out of windows during 9-11) or parents communicating to their children the dangers of being in a parking garage of a multi level building at night alone, being raped or attacked.
The criteria for a specific Phobia includes:
1. An excessive, persistent, unreasonable fear triggered by the presence or anticipation of a specific object or situation (e.g. driving, flying , blood)
2. Exposure to the phobic object or situation causing an anxiety response. In children anxiety may be manifested by crying, clinging, tantrums.
3. The fear is excessive and unreasonable.
4. The object or situation is avoided or endured with intense distress.
5. The individual’s daily functioning work, or intellectual functioning and social relationships are severely impacted by distress when having the phobia.
Social Phobia
A Social Phobia or Social Anxiety Disorder is a recurring and enduring fear dealing with social performance situations, in which the individual feels socially inferior and embarrassed, resulting in immediate anxiety, low self esteem, and a lack of self-confidence. The behavior may manifest itself in this situation as a panic attack with intense fear or discomfort with four (4) or more symptoms: (1) rapid heartbeat, (2) perspiration or sweating, (3) dizziness or lightheadedness, (4) shaking, (5) vomiting or stomach upset, (6) choking, (7) chest pain, (8) feeling a loss of control, (9) feelings of loss of reality, (10) feeling as if you are dying, (11) tingling sensations, (12) chills, (13) shortness of breath, (14) feelings of loss of control. The social situation is strongly avoided. The person will maintain avoidance, have fear and will have anxious anticipation of the social situation, so much that it will interfere with the persons social life, occupational functioning, and daily routine in life The person who has Social Phobia worries that strangers or others will be judging them, what others think of them believing that others will perceive them in some inferior manner often avoiding such performances as, eating, drinking or talking in public, fearing that others may see their anxiety or panic like symptoms of shaking, trembling, sweating, redness in the face, confusion and difficulty talking.
It should be noted that this diagnosis should not be given if the fear is reasonable, as for example, being called on to recite information and not having done the assignment in class or at work. The person with Social Phobia will avoid the feared situation. Anticipatory anxiety may well be occurring on a daily basis, should the person be worrying about having to attend an upcoming social event weeks prior to the event. A person who has Social Phobia is typically a person with low-self esteem has feelings of inferiority, is hypertensive to criticism, rejection and being evaluated by others. They may present themselves to others having poor eye contact, they will lack social skills, and present noticeable signs of anxiety, such as voice tremor, trembling, cold or sweating hands and noticeable fidgety body movements. They tend to receive low test scores, due to anxiety and lack of classroom participation. They may be underachievers at work, due to avoidance of group participation and talking to authority figures and colleagues at work. In more severe cases they may be unemployed, avoid job interviews, have no or few friends, avoid dating, be unmarried and remain in the home of their parents, well into older age. A diagnostic criteria for Social Phobia includes: (1) A fear of being in social or performance situations and having to interact with other people, feeling embarrassed and humiliated (2) Exposure to the feared social situation provokes anxiety or panic attack (3) The person recognized the fear is excessive or unreasonable (4) The feared social or performance situations are avoided or tolerated with intense anxiety (5) In the feared situations, the distress, anticipatory anxiety, and avoidance has a detrimental impact on the person’s career, job functioning, social functioning and daily functioning (6) Under 18 years of age duration of six (6) months (7) The fear of avoidance is not due to any effects of drugs or medication.
Obsessive Compulsive Disorder
Obsessions are recurrent intrusive thoughts that cause emotional distress. The obsessions, for example, may be about, not touching anything when in a public bathroom, for fear of becoming contaminated with germs, or severe distress when household items are not put in their right place, or sexual images or positions that are sexually arousing. Compulsions are ritualistic or repetitive behaviors, such as repeated checking to see if the door is locked or repeating over and over, the same communication. Compulsions may be repetitive behaviors, such as repetitive checking, or repetitive placing ones gym clothing in a bag for the correct positioning, or washing of the hands. Compulsions may also be mental acts, such as counting in sets of fifty’s (50’s), ten times, or praying, or thoughts of neogelistic words which reduces anxiety, stress and distress. Resisting compulsions and obsessions may precipitate anxiety. Giving in to them will relieve the tension thereby reinforcing and incorporating the obsession or compulsion into the individual’s daily routine. Obsessions and compulsions cause serious emotional distress usually consuming one (1) or more hours per day. Obsessive and compulsive functioning interferes with cognitive functioning affecting performance and concentration. The individual with the obsessive-compulsive disorder does not recognize that this disorder is excessive and dysfunctional. Avoidant behaviors manifest themselves in the obsession or compulsive state, such as an individual who is a hypochondrial nature seeking medical support, or treatment. Although ritualistic behavior is not an indicator of Obsessive-Compulsive Behavior, unless it is out of the social context within the culture or is not within the role of societal norms. For example, in the Greek culture, a woman who is young (in her twenties) or older (in her sixties) who has lost her husband may continue to mourn her husband ten years or to the end of her life, wearing the color black, covering her head with a black shawl, not participate in social events, especially where there is music and social gatherings of food and parties. This is not an obsession, but a context of the culture.
The diagnostic crieteria for Obsessive-Compulsive Disorder includes: (1) Persistent ongoing, intrusive thoughts, scenes, impulses, that are out of context causing emotional distress and nervousness (2) These thoughts, impulses and images are not just worries about life concerns (3) The individual tends to reject these thoughts, impulses and images with other actions or thoughts (4) The individual is cognizant that these thought are a product of his own mind (5) The compulsions are repetitive behaviors (washing of hands, etc.) or mental acts (repeating numbers, etc.) that the individual feels he must perform (5) These behaviors or mental acts decrease the stress (6) The individual realizes that these obsessions and compulsions are out of control and unrealistic (7) The obsessions and compulsions cause severe emotional upset and are very consuming taking over one (1) hour per day, interfering with the person’s daily functioning, work and social functioning (8).