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ANXIETY DISORDERS



Anxiety is a natural emotion which, in itself, is useful for adaptation. It suffices to say though, that without anxiety and fear, mankind would not have survived the past and would not be able survive future dangers. Without resorting to extreme examples, anxiety can be thought of as an ally in times when we must face a test, an exam or a situation which requires a great deal of attention and concentration. A certain amount of anxiety is therefore useful in everyday life, but in some situations, when we are too anxious, we may freeze up or panic and it may become pathological.
Anxiety can be an expression of an internal conflict, which must be investigated before being solved. It can represent a signal in response to which defence mechanisms are put into place in order to stop unacceptable thoughts and feelings becoming conscious. From a physiological point of view, anxiety occurs through neurovegetative activation, which concerns the limbic system, the orbital frontal cortex, vegetative nuclei of the brainstem and the automatic nervous system (sympathetic or parasympathetic). This physiological activation is the same for anger, with the only difference being the cognitive interpretation given to the situation which is being experienced.
In general, anxiety can be defined as a consequence of the underestimation of one's abilities to deal with an event and an overestimation of the difficulty of the event.
A similar definition could also be attributed to depression, however the difference is that, with anxiety, the sufferer is able to see a solution and this person is actively searching for coping strategies to deal with reality, while depressed subjects see no way out and are, so to speak, resigned.

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) classifies and describes the following anxiety disorders:
- Panic attack;
- Panic disorder without agoraphobia;
- Panic disorder with agoraphobia;
- Agoraphobia without history of panic disorder;
- Specific phobia;
- Social phobia;
- Obsessive compulsive disorder;
- Post-Traumatic stress disorder;
- Acute stress disorder;
- Generalised anxiety disorder.

In many cases, psychotherapy proves useful when it complements the administration of anti-anxiety drugs or antidepressants, prescribed by a doctor, to treat acute and often disabling symptoms. It also enables the patient to benefit from a treatment course with the help of a professional, who can help the patient to understand the significance of the disorder, its elaboration and how it changes a person’s behaviour. The cognitive-behavioural approach, for example, analyses cognitive models, which perpetuate thoughts and erratic behaviour, and it involves teaching the patient specific relaxation and stress management techniques. Combining medication and cognitive-behavioural therapy seems to work better than just one of these treatments alone.
In fact, in many cases, medication reduces anxiety temporarily but does not change the model of learning which underlies and perpetuates anxiety. In cognitive-behavioural therapy, it is assumed that, at the bottom of anxiety and pathological phobias, lies a cognitive distortion produced by automatic negative thoughts, which are the results of a schema of danger/threat, a nucleus which is activated in situations that are more or less specific, and these are what the therapist must work on. What is the patient afraid of? What are the situations that activate and generate anxiety and/or panic attacks or, more generally, what are the symptoms of anxiety?
It is important that the patient receives information about his/her symptoms and is helped to understand exactly what he/she is afraid of, restructure any dysfunctional thoughts, identify trigger situations, improve self-esteem and stress and time management and highlight the skills he/she possesses which will help to solve problems in other areas of his/her life.
Before working on the patient's anxious states, the therapist needs to investigate what factors are maintaining the disorder, which may be the results of behavioural avoidance (for example, negative reinforcement), cognitive distortions and secondary benefits (for instance, manipulation of family relationships, taking on the role of patient or distancing oneself from the sense of responsibility). The change begins when the factors keeping anxiety present and hindering motivation towards self-realisation are removed.
Behavioural treatment techniques can be used, such as autogenic training (relaxation technique based on the relationship between mental states - including emotions - and somatic aspects of the individual) and systematic desensitisation.
Systematic desensitisation involves preparing a hierarchy of anxiety-producing stimuli, placed in ascending order, teaching a relaxation technique, visualising, in a relaxed state, the situation in which a stimulus creates less anxiety, and then gradually moving on to the hierarchy's successive scenes.
It is important that the patient knows about the physiological progress of anxiety as, quite often, patients believe their anxiety develops in two stages, the first being its unexpected arrival and the second being the end of the anxiety (although the latter is not foreseen during the peak of anxiety, thus it is thought that anxiety is never-ending).
The patient, helped by the professional, must learn to recognise the intermediate steps of his/her state of anxiety and, thanks to internal dialogue, learn how to confront these steps in effective ways. A patient's dysfunctional internal dialogue is what keeps an anxiety disorder alive, therefore changing it is essential.
Psychodynamic approaches can also be effective, especially in terms of working out what the underlying conflicts are.

Below we will review some anxiety disorders according to how they are coded in the DSM-IV, with specific guidance about how to treat the disorders.

Panic attacks or panic disorders without agoraphobia
A panic attack is essentially characterised by a precise period during which there is a sudden onset of fear (or even terror) and a very intense feeling of discomfort, even though there is no real danger. The attack starts suddenly and is accompanied by other symptoms (at least 4) such as palpitations, sweating, shaking, shivers, chest pains, feeling like you are suffocating, feeling like you are choking, dizziness, nausea, fear of going crazy, fear of dying, derealisation, depersonalisation, and so on. The symptoms, which are usually physical, are similar to the initial phases of a heart attack and are often accompanied by a sense of danger or imminent catastrophe and a need to get away from where one is.
This is not a codable disorder therefore a specific diagnosis is needed in the field in which the attack occurs, for example, the field of panic attacks with agoraphobia (frequent panic attacks with sudden recurrence and continual worry about their return which has significant consequences and changes the sufferer's attack-related behaviour). This disorder can be privy of psychological content and, in some cases, it appears that the attack comes out of nowhere, without any apparent precipitating environmental or intra-psychical factors being present.
The main point to explore is the type of conflict expressed through the panic attack. In order to do this, it is useful to collect information about the circumstances of the onset (where the person was, where the person was going, what he/she was doing, who the person was with, etcetera), the reason why the patient is asking for help now and how much the disorder affects the patient’s overall functioning.
It is also important to analyse and probe why the patient has signed up for help: quite often family members, stressed out by the consequences of the disorder or worried about it, have pushed the patient to seek help, or go to a doctor. It is also quite common that the first type of help the patient has sought was that of a doctor, given the somatic consequences of the attacks, but when no physical diagnosis was found, it would have been important for the patient to seek help elsewhere. It may not be easy for the sufferer to accept that he/she has a psychological problem, rather than a physical problem, therefore sufferers are not always motivated to go to a psychological consultation or pursue psychotherapy.
It has been found that patients have often experienced a loss in the month before the first panic attack occurred.
See Panic attacks

Agoraphobia is not a codable disorder therefore a specific diagnosis is needed in the field in which the attack occurs, that is, panic attack disorders with agoraphobia or agoraphobia without a history of panic disorders.
The sufferer feels a strong feeling of anxiety when he/she is in a situation in which he/she feels it would not be possible to get out of if the sufferer had a panic attack. Attacks occur primarily when the sufferer is away from home, thus the sufferer tries to avoid going out as much as possible and when he/she does go out, he/she looks for someone to go with and often talks about feeling like he/she is floating, is confused and does not have enough air to breathe.
It is essential to explore the conflict between dependency and independency, questioning which is more dominant, what the agoraphobia depends on (keeping in mind that the disorder could be a way to be in control of oneself or others, which is why these disorders are sometimes linked to past problems regarding separation-individuation) and exploring the reason why the patient wants help.

Panic disorders with agoraphobia are characterised by frequent panic attacks and agoraphobia which lead on to serious impairment of the autonomy of the sufferer, who asks to be accompanied when leaving the house or asks that someone replaces him/her to carry out various commitments.
It is important to investigate whether the agoraphobia was the result of a attack of panic, thus it can be classified as reactive.
The therapeutic treatment depends on the coding of the diagnosis, however, since agoraphobia occurs within the neurotic field (not psychotic, in which there is a detachment from reality) expressive therapy can be used, with three possible therapeutic approaches:
- Cognitive-behavioural approach: this involves replacing dysfunctional thoughts with functional thoughts;
- Systematic approach: this involves trying to change the balance of the family group, starting from the disorder suffered by the patient, which probably acts as a scapegoat, reworking the themes of dependency and encouraging the release and identification of members of the system;
- Psychodynamic approach: this tends to rework the terms of the conflict between dependency and independency and overcome symbiosis, thus encouraging the development of independence, overcoming a bereavement, if appropriate, strengthening internal borders and channelling aggression.

Specific phobia is characterised by clinically significant anxiety provoked by exposure to a feared object or situation, which often leads onto avoidance behaviour.
Adolescents and adults recognise the excessiveness and irrationalness of the fear. For subjects aged less than 18 years old, symptoms must persist for at least 6 months before a diagnosis of specific phobia can be made.
According to a psychodynamic point of view, each phobia has a component of repulsion and subconscious attraction to the feared object, which is contrasted by the following three defence mechanisms: displacement, projection and avoidance, which act simultaneously. Fear is moved by internal objects and projected onto external objects, which are avoided as much as possible.
Here are some of the various types of DSM-IV phobias:
- animal phobia: a phobia of one or more types of animals;
- natural environment phobia: an excessive fear of events or elements, like height, water, space;
blood phobia: a phobia of injections or injuries;
- situational phobia: phobia of being stuck in a tunnel, lift or on a bridge.
It is important to investigate what the feared objects and situations are, what their symbolic meaning is, what the internal feared objects are, if there any possible, unacceptable urges, the way in which the phobia has been dealt up until now, any possible secondary side effects of the disorder and the period and circumstances of the onset.

Since there is still a relationship with reality, expressive therapy can be used for special phobia too and there are three possible approaches which can be undertaken:
- Cognitive-behavioural approach: this involves replacing dysfunctional thoughts with functional thoughts;
- Systematic approach: this is based on techniques such as systematic desensitisation towards the stimulus or gradual immersion in anxiety-inducing situations;
- Psychodynamic approach: this tends to rework the terms of the conflict represented symbolically by the feared object.

Social phobia is a marked and persistent fear of social situations, performances that one might have to do in front of others and the consequential judgement of these. Exposure to such stimuli results in a generally anxious response, which may take the form of a panic attack. The sufferer recognises that the fear is excessive and unreasonable and implements avoidance behaviour, or deals with the situation or feared performance with great discomfort. All of this interferes significantly with the individual's professional or social functioning.
It is important to investigate:
- what the social situations are that create discomfort and what experiences arouse the phobia;
- how the subject has lived and dealt with issues related to being the centre of attention and showing off, issues which, according to the person's psychodynamic conception, predominate in the phallic-oedipal phase;
- the period and circumstances of the onset of the disease.
A therapeutic, cognitive-behavioural course may be useful in this case too (involving techniques like deconditioning towards feared social situations or gradual immersion in anxiety-inducing situations) or a psychodynamic approach which tends to encourage a process of awareness of the terms of the conflict and promote individual affirmation. See social phobia.

Obsessive compulsive disorder
The essential features of OCD are recurrent obsessions or compulsions which waste more than one hour of the sufferer's time per day or which cause significant distress to the sufferer.
Obsessions are represented by ideas, impulses and mental representations which become conscious in an inappropriate and intrusive way and against the wishes of the patient, who feels these things are foreign, abnormal, inappropriate and ego-dystonic.
The most common obsessions regard:
- aggression: fear of hurting oneself or others and fear of saying something obscene;
- contamination: worrying about dirt, faeces and/or getting ill;
- sex: prohibited or perverse thoughts or images, incestuous thoughts or homosexuality;
- hording: collecting the most varied objects, collecting items that have been stolen (these latter aspects are closer to psychosis).
The most common compulsions are:
- repetitive behaviour: like rituals, for example, washing one’s hands repetitively, putting objects in a certain order, etcetera;
- mental actions: such as counting, mentally repeating words, etcetera.
Whether it is repetitive behaviour or mental acts, compulsions are intended to prevent or reduce anxiety or distress, and not to provide pleasure or gratification. They cause marked distress, interfering with the sufferer's professional and social functioning and relationships and cause a withdrawal of affection.
Awareness of the illness (insight) is recorded, although the patient criticises these ideas, considering them to be a morbid mental production.
It is important to:
- find out what would happen, according to the patient, if he/she could not perform the ritual;
- collect information about the different development stages, with particular reference to the anal phase;
- know how long the disorder has been present for, what were the circumstances of the onset and why the patient is asking for help now;
- analyse the request for help in order to understand the needs and expectations of the subject.
From a psychodynamic point of view, fixation or regression to the anal state is hypothesised, where issues related to control of one's body and the conflict between holding and expelling predominate. Many authors also believe that, in some cases, behavioural conditioning can be useful as a form of primary treatment for compulsions, although the treatment seems to be less effective for obsessive thoughts. Systematic desensitisation is also used, as well as cognitive behavioural therapy, through which the aim is to replace obsessive ideas with rational thoughts, which affect the welfare of the sufferer.
Psychodynamic therapy can be an effective way to deal with secondary relationship problems: it can significantly improve OCD patients' interpersonal skills. Group or family dynamic psychotherapy can also be helpful, since the family is often heavily involved in the manifestations and consequences of the disorder. A psychodynamic approach promotes the process of reworking the terms of the conflict by encouraging channelling, satisfaction and management of unacceptable compulsions.
It is also important to analyse the factors which trigger or aggravate the symptoms since, by helping patients and their families to understand the nature of these stressors, symptoms can be managed more effectively.

Generalised anxiety disorder is characterised by at least 6 months of feeling anxious and worried almost all day, feelings which are difficult to control and which concern a variety of issues. These worries are manifested through the body (muscle tension, fatigue, etcetera) and they affect the mood and sleep. It is important to explore the conflict and underlying urges of anxiety symptoms, know how long the problem has been around for, what the circumstances of the onset were, what the anxiety is mainly about and what time of day and under what circumstances its symptoms appear. Since anxiety is a signal of danger, it is important to understand what the subject wants to protect him/herself from, the level of impairment of functional areas, what defensive styles have been implemented and self-perception.
In acutely anxious individuals, anxiolytic drugs are undoubtedly effective since they rapidly reduce the symptoms, especially in the early weeks of therapy. Given the risk of developing drug addiction, most experts agree that anxiolytics should be prescribed at the lowest possible dose for the shortest time possible. Milder forms of GAD are best treated with psychotherapy, during which patients are taught strategies to manage their anxiety; for example, cognitive-behavioural therapies teach patients to see how much their thoughts and unrealistic worries affect their behaviour.
Many anxious people are worried about being unable to cope with anxiety and they fear losing control, going crazy or be publicly embarrassed. Consequently, these fears increase their anxiety, thus creating a vicious circle: the anxious thoughts increase the anxiety symptoms which, in turn, generate even more anxious thoughts. Cognitive-behavioural techniques help patients to break this cycle by allowing them to adequately deal with the anxious thoughts and their relative behavioural manifestations. A psychodynamic approach may be useful on the assumption that anxiety is a sign which expresses underlying discomfort. The role of anxiety in the organisation of the patient's personality must also be assessed. Some patients may respond rapidly to short educational and enlightening comments, thus they do not need further treatment.

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