The closing stages of the Oscar Pistorius trial have taken an interesting twist with forensic psychiatrist Dr Merryl Vorster describing the accused's "Anxiety disorder." Dr. Vorster went on to claim that, due to this disorder, Pistorius was much more likely to react to a stressful situation with a "fight" rather than "flight" response. She also claimed that a person who suffered from such a disorder and in possession of a gun would be "dangerous."
- There are different types of anxiety disorders. Each is characterised by different kinds of fears or concerns. Typically the person recognises that the fear is excessive or irrational.
- Anxiety disorders are frequently undiagnosed and undertreated.
- Treatment usually takes the form of cognitive-behavioural therapy and/or medication.
- Conditions such as depression, alcoholism, substance abuse or eating disorders can accompany an anxiety disorder.
Everybody knows what it's like to feel anxious – the butterflies in your stomach before a first date, the tension you feel when someone important to you is angry with you, the way your heart pounds if you're in danger. Anxiety rouses you to action. It gears you up to face a threatening situation. It makes you study harder for an exam, and keeps you on your toes when you're making a speech. In general, it helps you cope.
But if you have an anxiety disorder, this normally helpful emotion can do just the opposite – it can keep you from coping and disrupt your daily life. Anxiety disorders aren't just a case of "nerves." They are illnesses, often related to the biological makeup and life experiences of the individual, and they frequently run in families.
There are several types of anxiety disorder, each with its own distinct features. An anxiety disorder may make you feel anxious most of the time, without any apparent reason. Or the anxious feelings may be so uncomfortable that to avoid them you may stop everyday activities. Or you may have occasional bouts of anxiety so intense they terrify and immobilise you.
Many people have a single anxiety disorder. But it isn't unusual for an anxiety disorder to be accompanied by another illness, such as depression, an eating disorder, alcoholism, drug abuse, or another anxiety disorder. In such cases, these problems will need to be treated as well.
Types of Anxiety Disorders
Generalised Anxiety Disorder (GAD)
A person suffering from Generalised Anxiety Disorder (GAD) might describe their condition as follows: "I always thought I was just a worrier. I'd feel hyped-up and unable to relax. At times this feeling would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to wear to work, or what would be a great present for somebody. I just couldn't let something go. I'd have terrible sleeping problems, and trouble concentrating, even when watching TV or reading. Sometimes I'd feel physical symptoms such as light-headedness or my heart would pound. That would make me worry even more."
GAD is much more than normal day-to-day anxiety. It's chronic, exaggerated worry and tension. Having this disorder means always anticipating disaster and often worrying excessively about health, money, family or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day may provoke anxiety. People with GAD can't seem to shake their concerns, even though they usually realise their anxiety is more intense than the situation warrants. People with GAD also seem unable to relax. They often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, hot flushes, and feeling light-headed or breathless. They may feel nauseated or have to visit the bathroom frequently. Or they might feel as though they have a lump in the throat.
"For me, a panic attack is almost a violent experience. I feel like I'm going insane. It makes me feel like I'm losing control in a very extreme way. My heart pounds really hard, things seem unreal, and there's a powerful feeling of impending doom. Between attacks there's dread and anxiety that it's going to happen again. It can be very debilitating, trying to escape those feelings of panic."
People with panic disorder have feelings of terror that strike suddenly and repeatedly without warning. They can't predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next will strike. Between attacks there is a persistent worry that another attack could come any minute. When a panic attack strikes, typically the heart pounds and they feel sweaty, weak, faint or dizzy. Their hands may tingle or feel numb, and they might feel flushed or chilled. They may have chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. They may believe they're having a heart attack or stroke, losing their mind, or are on the verge of death. Attacks can occur at any time, even during non-dream sleep.
Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may lead to phobias of places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding in a lift, you may develop a fear of lifts and perhaps start avoiding them. Some people's lives become greatly restricted – they avoid everyday activities such as shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person. Basically, they avoid any situation they fear might make them feel helpless should a panic attack occur. When people's lives become so restricted by the disorder, as happens in about one-third of all panic disorder sufferers, the condition is called panic disorder with agoraphobia.
Phobias aren't just extreme fear; they are irrational fear. Adults with phobias realise their fears are irrational, but often facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.
A specific phobia is the intense, irrational fear of specific objects or situations that cause terror. Specific phobias can be classified into subtypes, namely Animal Type, Natural Environment Type (eg storms, heights or water), Blood-Injection-Injury Type (eg seeing blood or an injury), Situational Type (eg public transportation or enclosed places) or Other Type (if fear is cued by other stimuli).
Social Anxiety Disorder (Social Phobia)
"I couldn't go on dates or to parties. For a while, I couldn't even go to lectures. During my first year at university, I had to come home for a semester. My fear would happen in any social situation. I'd be anxious before I even left the commune where I lived, and it would escalate as I got closer to class, a party, or whatever. I'd feel sick to my stomach – it almost felt like I had 'flu. My heart would pound, my palms sweat, and I'd get this feeling of being removed from myself and from everybody else. When walking into a room full of people, I'd turn red and it would feel like everybody's eyes were on me. I was too embarrassed to stand off in a corner by myself, but couldn't think of anything to say to anybody. I felt so clumsy, I couldn't wait to get out."
Social anxiety disorder (social phobia) is an intense fear of becoming humiliated in social situations; in other words, of embarrassing yourself in front of others. It often runs in families and may be accompanied by depression or alcoholism. Social anxiety disorder often begins in early adolescence or even younger. If you suffer from social anxiety disorder, you tend to think other people are very competent in public and that you are not. Small mistakes you make may appear much more serious to you than they really are. Blushing may seem painfully embarrassing, and you feel as though all eyes are focused on you.
Your fear may be specific (such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating) or generalised to most social situations. The most common social anxiety disorder is fear of public speaking. More rarely it may involve a fear of using a public toilet, eating out, talking on the phone, or writing in the presence of other people, such as when signing a cheque.
Social anxiety disorder should not be confused with shyness. Shy people can be very uneasy around others, but they don't experience extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious. In contrast, people with social anxiety disorder aren't necessarily shy. They can be completely at ease with people most of the time, but particular situations such as making a speech can give them intense anxiety. Social anxiety disorder disrupts normal life, interfering with career or social relationships. For example, an employee might turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.
People with social anxiety disorder are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and may go out of their way to avoid it. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout the situation. Afterwards, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them
Obsessive-compulsive Disorder (OCD)
"I couldn't do anything without rituals. It transcended every aspect of my life. Counting was big for me. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. If I was writing an essay for university, I couldn't have a certain number of words on a line if they added up to a bad number. I was always worried that if I didn't do something, my parents were going to die. Or I would worry about harming my parents, which was completely irrational. Getting dressed in the morning was tough because I had a routine, and if I deviated from it, I'd have to get dressed again. I knew the rituals didn't make sense, but I couldn't seem to overcome them until I had therapy."
Obsessive-compulsive disorder (OCD) is characterised by anxious thoughts or rituals you feel you can't control. The disturbing, intrusive thoughts or images such as those described above are called obsessions, and the rituals performed to try to prevent or dispel them are called compulsions. There is no pleasure in carrying out the rituals you feel compelled to perform, only temporary relief from the discomfort caused by the obsession.
Many healthy people can identify with having some of the symptoms of OCD, such as checking the stove several times before leaving the house. But the disorder is diagnosed only when such activities consume at least an hour a day, are very distressing, and interfere with daily life. Most adults with this condition recognise that what they're doing is senseless, but can't stop. Some people, however, particularly children with OCD, may not realise their behaviour is abnormal.
Depression or other anxiety disorders may accompany OCD. If OCD becomes severe enough, it can keep someone from holding down a job or carrying out normal responsibilities at home.
Post Traumatic Stress Disorder (PTSD)
"When I was 21, I was in a horrific car accident, in which my brother was killed and I ended up in hospital with severe injuries. I often spoke about the accident, but on a very intellectual level, almost as if it hadn't happened to me. Then, several years later, I started getting flashbacks of the car rolling and other images of the accident. This freaked me out. I also experienced physical symptoms such as cold sweats and headaches, and became extremely anxious every time I travelled anywhere by car. This seemed almost unreasonable."
Post-traumatic stress disorder (PTSD) is a debilitating condition that follows a terrifying event, such as a violent attack, an accident or a natural disaster. The person may experience the traumatic event directly, may witness an event that involves other people or may learn about a traumatic event that happened to a family member or close friend.
It should be emphasized that most people who are exposed to traumatic events do not develop PTSD. Furthermore, many people with symptoms (such as difficulty falling asleep) after a trauma show gradual improvement with time. However, in some cases, PTSD symptoms continue and negatively impact on the person’s life. In such cases, PTSD may be present.
Some people with PTSD repeatedly relive a trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or are easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, and even violent. Seeing things that remind them of the traumatic incident may be highly distressing, and could lead them to avoid certain places or situations that trigger traumatic memories. Anniversaries of the event are often very difficult times. In severe cases people with PTSD may have trouble working or socialising.
Causes and risk factors
Each of the anxiety disorders seem to be underpinned by various brain circuits and brain chemicals that mediate anxiety symptoms. Other factors such as infection may also disrupt brain circuitry and cause for example OCD.
Generalised Anxiety Disorder
Generalised anxiety disorder (GAD) is characterised by excessive anxiety and worry. The person finds it difficult to control the worry and may feel tired, restless, irritable, have difficulties with sleep and/or concentration. As in the case of other anxiety disorders, GAD can be very debilitating, making it difficult to carry out ordinary daily activities.
Panic Attack Symptoms:
- Chest pains or a pounding heart
- Light-headedness or dizziness
- Nausea or stomach problems
- Flushes or chills
- Shortness of breath or a feeling of smothering or choking
- Tingling or numbness
- Shaking or trembling
- Feelings of unreality
- A feeling of being out of control or going crazy
- Fear of dying
An intense and irrational fear of an object or situation typically leading to avoidance although the feared object or situation may be endured with dread.
OCD is characterised by recurrent obsessions or compulsions that are time consuming, distressing to the person or impairs the person’s functioning. Usually the person is aware that the obsessions or compulsions are excessive or unreasonable. On occasion, however, the person may be convinced that their obsessions/compulsions are reasonable.
Post-Traumatic Stress Disorder
Persons with PTSD display three types of symptoms:
- Intrusive re-experiencing symptoms are when a person has memories, flashbacks or nightmares of the event(s).
- Avoidant or numbing symptoms are when a person withdraws from people or activities that are reminders of the traumatic event.
- Hyperarousal symptoms are when a person is easily startled, irritable, on edge or has trouble falling asleep.
When children have PTSD, symptoms are expressed in different ways. For example, children may re-experience the traumatic event through repetitive play (e.g., a child who witnessed a robbery may re-enact the robbery again and again using her toys). Scientists have suggested that PTSD tends to be more intense and lasts longer when the traumatic event involves human violence. They have also found good evidence that the likelihood of developing PTSD increases with the severity, length and proximity of exposure to the traumatic event.
Generalised Anxiety Disorder
GAD is more common in women than men and often occurs in relatives of affected persons.
Panic disorder is twice as common in women as in men. It can appear at any age, but most often begins in young adulthood. Not everyone who experiences panic attacks will develop panic disorder; many people have only one attack in their lifetimes.
Specific phobias strike more than 1 in 10 people. They are slightly more prevalent in women.
OCD strikes men and women in approximately equal numbers and afflicts roughly one in 50 people. It can appear in childhood, adolescence or adulthood, but on average it first shows up in the teens or early adulthood. A third of adults with OCD experienced their first symptoms as children.
Post-Traumatic Stress Disorder
PTSD can occur at any age, including childhood.
When to call a health professional
It is important to seek professional help if you are experiencing symptoms of an anxiety disorder. If left untreated, the disorder can become disabling.
A clinician (usually a GP) makes the diagnosis. A psychiatrist should do a thorough assessment, including taking an in-depth history of the patient and his or her family. The diagnosis is made according to the criteria in the DSM-IV (American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders).
For example, to make a diagnosis of panic disorder, clinicians will need to confirm that panic attacks are followed by at least one month of continual worry about having another attack, as well as its implications or consequences, and that the attacks have led to significant behaviour changes (e.g. agoraphobia).
Many people misunderstand these disorders and think individuals should be able to overcome the symptoms by sheer willpower. Wishing the symptoms away does not work – but there are treatments that can help.
If you or someone you know has symptoms of anxiety, a visit to the family physician is usually the best place to start. Your doctor can help you determine if the symptoms are due to an anxiety disorder, some other medical condition, or both. Most often, the next step to getting treatment for an anxiety disorder is referral to a mental health professional. Among the professionals who can help are psychiatrists, psychologists, social workers and counsellors.
Remember that when you find a health care professional you're satisfied with, the two of you will work as a team. Together you will develop a plan to treat your anxiety disorder that may involve medication, behavioural therapy, cognitive-behavioural therapy, or another form of psychotherapy as is appropriate.
Psychologists, social workers and counsellors sometimes work closely with a psychiatrist or other physician who will prescribe medications when they are required. For some people, group therapy or self-help groups are a helpful part of treatment. Many people do best with a combination of these therapies.
If you have been taking medication, don't stop taking it abruptly - rather taper the dose off under a doctor's supervision.
Therapy for anxiety disorders often involves medication or specific forms of psychotherapy. First line medication is certain kinds of antidepressants although other agents are used at times. Medications, although not cures, can be very effective at relieving anxiety symptoms. For most of the medications that are prescribed to treat anxiety disorders, the general practitioner or psychiatrist usually starts the patient on a low dose and gradually increases it to the full dose. Every medication has side effects, but they usually become tolerated or diminish with time. If side effects become a problem, the doctor may advise you to stop taking the medication and wait before trying another drug. When treatment is near termination, the doctor will taper the dosage gradually.
Research has also shown that behavioural therapy and cognitive-behavioural therapy can be effective for treating anxiety disorders. Behavioural therapy focuses on changing specific actions and uses several techniques to decrease or stop unwanted behaviour. For example, one technique trains patients in diaphragmatic breathing, a special breathing exercise involving slow, deep breaths to reduce anxiety. People who are anxious often hyperventilate, taking rapid shallow breaths that can trigger symptoms such as rapid heartbeat and light-headedness.
Another technique, exposure therapy, gradually exposes patients to what frightens them and helps them cope with their fears. Behavioural therapy and cognitive-behavioural therapy teach patients to react differently to the situations and bodily sensations that trigger panic attacks and other anxiety symptoms. Patients also learn to understand how their thinking patterns contribute to their symptoms and how to change their thoughts accordingly. This awareness of thinking patterns is combined with exposure and other behavioural techniques to help people confront their feared situations. For example, a man who becomes light-headed during a panic attack and fears he is going to die can be helped with the following approach used in cognitive-behavioural therapy: The therapist asks him to spin in a circle until he becomes dizzy. When he becomes alarmed and starts thinking, "I'm going to die," he learns to replace that thought with a more appropriate one, such as "It's just a little dizziness – I can handle it."
Treatments for anxiety disorders, however, may not start working instantly. Your doctor or therapist may ask you to follow a specific treatment plan for several weeks to determine if it's working.
Generalised Anxiety Disorder
Successful treatment may include medication and psychotherapy. Certain antidepressants have been successful in helping people with this disorder. In some cases, other agents (e.g. benzodiazepines) are used. Also useful is cognitive-behavioural therapy.
Studies have shown that proper treatment with cognitive-behavioural therapy, medications, or possibly a combination of the two helps 70 to 90 percent of panic disorder sufferers. Significant improvement is usually seen within six to eight weeks.
Cognitive-behavioural approaches teach patients how to view the panic situations differently and demonstrate ways to reduce anxiety, using breathing exercises or techniques to refocus attention, for example. Exposure therapy is also used to help alleviate phobias that may result from panic disorder. In exposure therapy, people are very slowly exposed to the fearful situation until they become desensitised to it. Some people find the greatest relief from panic disorder symptoms when they take certain prescription medications. Two types of medications shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines.
If the object of fear is easy to avoid, people with phobias may not feel the need to seek treatment. Sometimes, though, they may make important career or personal decisions to avoid a phobic situation. When phobias interfere with a person's life, treatment can help. Successful treatment usually involves CBT techniques such as desensitisation or exposure therapy, in which patients are gradually exposed to what frightens them until the fear begins to fade. Three-quarters of patients benefit significantly from this type of treatment. Relaxation and breathing exercises also help reduce anxiety symptoms.
Sometimes certain medications may be prescribed to help reduce anxiety symptoms before someone faces a phobic situation.
Social anxiety disorder
About 80 percent of people who suffer from social anxiety disorder find relief from their symptoms when treated with cognitive-behavioural therapy or medications or a combination of the two. Therapy may involve learning to view social events differently; being exposed to a seemingly threatening social situation in such a way that it becomes easier to face; and learning anxiety-reducing techniques, social skills and relaxation techniques.
Medications that have proven effective include antidepressants called SSRIs and MAO inhibitors. Drugs called Beta-blockers have helped people with a specific form of social anxiety disorder called performance phobia. For example, musicians or others with this anxiety may be prescribed a Beta-blocker for use about 30 minutes to an hour before a performance.
Medications and behavioural therapy can benefit people with OCD. A combination of the two treatments is often helpful for most patients. Medications that have been found effective in treating OCD are certain antidepressants that act on the serotonin system. Behavioural therapy, specifically a type called exposure and response prevention, has also proven useful for treating OCD. It involves exposing the person to whatever triggers the problem and then helping him or her forego the usual ritual – for instance, having the patient touch something dirty and then not wash his or her hands. This therapy is often successful with patients who complete a behavioural therapy programme, though results have been less favourable in some people who have both OCD and depression.
Post-Traumatic Stress Disorder
Antidepressants can ease the symptoms of depression and sleep problems; and psychotherapy, including cognitive-behavioural therapy, is also an integral part of treatment. Being exposed to a reminder of the trauma as part of therapy – such as returning to the scene of a rape – sometimes helps. And, support from family and friends can help speed recovery.
Early treatment can perhaps prevent the level of disability/dysfunction reached. Early treatment may help prevent the development of co-existing conditions such as depression and alcoholism.
Early treatment of panic disorder can often stop the progression to agoraphobia.
There is also some preliminary evidence to suggest that early treatment of a person who has been exposed to a terrifying trauma may prevent the onset of Post-traumatic Stress Disorder.
Previously reviewed by Dr Soraya Seedat, psychiatrist and co-director, MRC Unit on Anxiety and Stress Disorders.
Reviewed by Dr Stefanie van Vuuren, Psychiatrist, MB ChB (Stell), M Med (Psig) (Stell), FC (Psych)SA, February 2012.