Anxiety Disorders

Excerpted from
Adult Psychopathology: Second Edition
By Francis J. Turner, Ph.D.

Current subject matter in newspapers, magazines, and bookstores reflects a broad-based societal concern about anxiety. Young parents, struggling to balance the conflicting demands of career advancement and "normal" family living, worry that their efforts in either direction interfere with success in the other. Single parents, alternate lifestyles, reconstituted families, sandwich generations, etc., make up such a large part of our population that it is difficult for an individual to find a reference point to evaluate the appropriateness of his or her behavior. Furthermore, rapid technological advances have produced an intensity of knowledge and information transmission to the extent that the experiences of "knowledge explosion" and "information overload" are commonplace, with individuals finding they must deal with a constantly increasing number of choices when making daily decisions.

To complicate matters, the health care industry is forced to struggle with insurance companies and administrators who exert as much influence as medical diagnosis and patient need in determining treatment direction, requiring a focus on "brief" therapies as a condition for payment. Thus, mental health practitioners are influenced to select treatment approaches that focus on symptom relief, unable to study the workings of the client's mind at leisure, with the goal of improving overall functioning.

Discussing anxiety disorders within the context of such societal and professional pressures tempts one to "jump on the bandwagon" of current disposition and concentrate essentially on symptom description, with emphasis placed on treatment approaches aimed at symptom alleviation. While such emphasis can help clients function better, it includes three significant shortcomings. It fails to account for the core of knowledge underlying our understanding of the anxiety experience, within which anxiety is viewed as a normal and potentially helpful feeling state; it fails to promote the client's capacity for anxiety tolerance as a necessary component of everyday living; and it overlooks improving the client's ability to cope by failing to deepen understanding of self within a rapidly changing and overstimulating social context. In other words, focus on symptom relief can help to diminish anxiety, but does little to enhance the client's appreciation of the need to expand a repertoire of coping skills that enable ongoing adaptive functioning. This chapter, by focusing on anxiety as a subjective phenomenon occurring as part of the client's normal everyday experience, considers anxiety and its disorders within the context of increasing self-understanding and the expansion of coping skills.

Psychological Aspects of Anxiety

The anxiety experience can occur anywhere and at anytime. The young woman in the above vignette was obviously waiting for someone whose arrival was important to her. We can imagine the possible circumstances a concert, a wedding, a dinner appointment. Her reaction was a subjective experience of stress and apprehension in relation to an event that was about to occur, and her specific mental state was that something terrible was about to happen: in her mind, she would soon find out that her date was dead.

In anticipating disaster, the woman found that her thoughts flowed into one another, her capacity to understand what was going on around her was diminished, and her body seemed to function in atypical and almost uncontrollable ways. Most significantly, she was acutely aware of herself and the way she was feeling. She was so uncomfortable, confused, and out of control that she felt she was floundering and unable to help herself. In short, this woman was experiencing an anxiety attack. While any of us may undergo such an experience on occasion, most of us are not generally subject to such extreme feelings of anxiety and are more used to the kind of apprehension experienced before taking a test, consulting a physician, or waiting for a job interview. We wonder about what could go wrong, anticipate that it might, worry about that to the point of feeling some of the physical reactions described in the vignette-but we basically retain a sense of control about ourselves and are able to attend to the business at hand despite the sense of distress.

Physiological Aspects of Anxiety

As was indicated in the vignette, physiological correlates of the anxiety experience may include any of the following 13 somatic or cognitive experiences:

• palpitations
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• dizziness or light-headedness
• derealization or depersonalization
• fear of losing control or "going crazy"
• fear of dying
• paresthesias
• chills or hot flushes

All of these indicators may not be present, but several usually occur in combination. However, some form of motor tension and autonomic hyper-activity is always present, so that the person inevitably experiences a sense of jumpiness, increased heart and breathing rates, and heightened blood pressure.

Of major interest with respect to the physiological correlates of the anxiety experience is that these physical reactions, among others, are not specific to anxiety per se (Krystal, 1997; Lichtenberg, 1991). A person experiencing anger, fear, or a general state of overexcitement (affect storm) may demonstrate similar physical reactions. If one were to monitor physiological responses to anger, fear, anxiety, excitement, or an affect storm of any kind, one would not be able to distinguish among the emotional states without knowledge of the person's mental state. In other words, the physiological correlates of anxiety can be ascribed to anxiety only if they are accompanied by the psychological experience of apprehension with respect to impending doom. Mental ideation and physiological process cannot be conceived of separately; neither by itself defines the anxiety condition.

Basic Concepts of Anxiety

Anxiety is an affect that occurs in all individuals. Like joy, sadness, bemusement, and even grief, anxiety arises and diminishes at various times and under various circumstances. The hallmark of anxiety is a feeling of apprehension, accompanied by the idea that something bad is about to happen.

For Brenner, the distinction between anxiety and depression is that anxiety is an anticipatory feeling of tension, whereas depression is a feeling of tension associated with the idea that something bad has already happened. The essential distinction is that anxiety serves as a warning about whatever doom is supposed to come; depression is felt after disaster has occurred. Within this context anxiety can function as a signal that motivates a person to act, in an attempt to "head off" the unpleasant outcome.

When the experience of anxiety does fulfill its anticipatory and motivating purpose, it can be understood as a way of preparing to deal with other, potentially debilitating aspects of anxiety. And when tolerance for the anxiety experience is available, or psychological defenses are working, anxiety is diminished and the ability to go about normal, daily business remains intact even though some apprehension or worry is felt. When defenses are not working, however, or tolerance is not available, anxiety does not decrease and an anxiety state (panic) occurs, during which it is not possible to continue normal routines. Thus, to fully appreciate the full scope of possible anxiety experiences, it is helpful to view anxiety from two perspectives, as a "signal anxiety" and as a "state." The former is a normal part of daily living, such as occurs during preparation for a job interview or an examination; in this case, anxiety serves as a motivator of activity whose purpose is to diminish apprehension. The latter is more problematic, since constructive functioning is not possible so long as a state of anxiety prevails.

Because correlates (symptoms) of anxiety are observable, it is possible to overemphasize them, designating the experience of anxiety as "a problem," rather than as an experience to be tolerated or as a possible motivating force. Maintaining a focus on the role of anxiety as a motivating force, however, in contradistinction to its experience as a mental or physical problem, permits the inference that an anxiety state occurs when the person is not able to tolerate its intensity (insufficient anxiety tolerance), or protect him/herself from it. In other words, even if the anticipatory function accompanies anxiety (signal anxiety), insufficient tolerance or non-availability of defenses may result in an anxiety attack.

Reviewing the above, then, anxiety can be either tolerated, during which experience the individual, though upset, is able to "go about everyday business" without having to do anything about the emotional distress, or it can be diminished when the person becomes able to invoke defenses for protection against a more intense feeling of anxiety. Most importantly, it is not the presence of the anxiety experience that is to be viewed as problematic; rather, it is the absence of anxiety tolerance or working defenses that results in psychological difficulty.