Common Anxiety Disorders

In all anxiety disorders, the core element is the occurrence of an anxiety reaction. Depression is the most common longitudinal outcome of most anxiety disorders. Early and first manifestations of anxiety may be expressions of the same type of underlying vulnerability for all types of anxiety disorders. The subsequent type of anxiety disorder expressed, the age expressed, and environmental events and other social factors serve to organize the particular psychopathology. In what follows I briefly explain five major anxiety disorders.

Panic disorder The central clinical feature of panic disorder is the spontaneous panic attack, a rapid increase of intense anxiety or fear that develops abruptly and peaks within 2-10 minutes, involving numerous cognitive and physical symptoms in multiple body systems. Apanic attack, as defined by DSM-IV, is a discrete period of intense fear or discomfort accompanied by at least 4 of 13 somatic symptoms. The core feature of panic disorder is the presence of recurrent spontaneous panic attacks followed by at least 1 month of persistent concern over having further attacks. The panic attacks in panic disorder are characterized by the absence of any situational trigger - they occur "out of the blue." As attacks recur and become more frequent, the individual develops intense worry regarding having future attacks. One of the consequences of this worry, or anticipatory anxiety, is the tendency to avoid situations where a panic attack may be likely to occur. Such avoidance behavior can eventually extend to other situations, and, in severe cases, can render the person housebound. Commonly individuals who suffer from panic disorder attribute their attacks to a life-threatening illness or to going mad or losing control (Sinha and Gorman, 2003; Nutt et al., 2001).

Social anxiety disorder Social anxiety disorder, also known as social phobia, is characterized by intense fear and avoidance of one or more social or performance situations, such as speaking in front of others, being watched while doing something, speaking to strangers, and meeting people in authority. Persons suffering from social anxiety disorder (SAD) are typically fearful of the possibility of being negatively evaluated by others or acting in a way that may be humiliating or embarrassing. The range of situations feared by persons with social anxiety disorder ranges from fear of a single situation such as performing on stage to fear of virtually all forms of interpersonal contact. The most commonly feared social situation is public speaking, followed by situations such as meetings, social events (e.g., parties) and interacting with authority figures. Women experience greater fear than men across a range of social situations (du Toit and Stein, 2001; Rapee etal., 1988; Turk etal, 1988).

90 Creativity, Spirituality, and Mental Health

Post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is precipitated by exposure to an event involving death, threatened death, serious injury, or threat to personal integrity (self or others) that causes intense fear, helplessness, or horror. Typical post-trauma symptoms are re-experiencing certain aspects of the trauma, avoidance of trauma-related stimuli, numbing, and increased arousal. Previous DSM definitions of PTSD stipulated that a "traumatic event" be outside the range of normal human experience; however, it is now believed that traumatic events are experienced by a large percentage of the population. Re-experiencing certain aspects of the trauma can include intrusive thoughts, nightmares, flashbacks, and emotional or physiological reactivity with reminders; avoidance/numbing responses can include avoidance of thoughts, feelings, activities, individuals, etc., associated with the trauma, inability to recall portions of the trauma, decreased interest in pleasurable activities, and foreshortened future perspective; arousal can include sleep problems, irritability and anger, difficulty concentrating, hypervigilance, and exaggerated startle. Prospective and retrospective studies indicate that the majority of individuals naturally recover from trauma. Trauma type, trauma severity, developmental factors, other psychopathology, and a history of traumatic events are all vulnerability factors (Rauch and Foa, 2003; Rothbaum et al., 1992).

Obsessive-compulsive disorder Obsessive compulsive disorder is characterized by the presence of recurrent obsessions and compulsions. Obsessions are ideas, thoughts, images, or impulses that intrude upon consciousness and cause marked anxiety. The ideas, etc., are experienced as alien and inappropriate, the most common being fears of contamination, doubts concerning past acts, aggressive or horrific impulses, and disturbing sexual imagery. Compulsions are defined as repetitive behaviors or mental acts that serve to prevent or reduce anxiety or to prevent a dreaded event, often associated with a compulsion. Compulsions are excessive and commonly involve washing and cleaning, mental counting and silent repetition, checking, repeating actions, and asking for reassurance. Obsessions and compulsions cause marked distress, are time-consuming (more than 1 hour per day), and significantly interfere with the individual's normal routine (Zohar et al., 2003; Nutt et al., 2001). In a study spanning six countries (Greenberg and Witzum, 1994), researchers found the content of obsessions to be relatively similar across locations: ranking the highest were dirt or contamination, harm or aggression, somatic, religious, and sexual obsessions.

Generalized anxiety disorder Generalized anxiety disorder is a common anxiety condition characterized by excessive and uncontrollable worry about a variety of domains (Borkovec et al., 1991, 2004; Craske et al., 1989). Common themes of worry in GAD include health, finances, performance at work or school, and interpersonal relationships (Rapee, 1991). Individuals who suffer from GAD believe that the world is a dangerous place and that they and their loved ones are especially vulnerable to experiencing negative life events. In short, they tend to

Issues of Mood and Anxiety 91

overestimate the perceived danger and underestimate their ability to cope with it. Nutt et al. (2001), explain that GAD is characterized by both psychological and physical symptoms. The prevalent psychological symptoms are a persistent feeling of fearful anticipation, irritability, poor concentration, and a feeling of restlessness. To meet DSM-IV criteria for GAD, the worry must be accompanied by at least three of the following: restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance. The physical symptoms stem from two principal sources: muscle tension and autonomic hyperarousal. Autonomic hyperarousal can cause numerous associated somatic symptoms, e.g., a feeling of tightness in the chest, palpitations, and chest pains. Often the physical symptoms of anxiety are the presenting complaint in general practice. In contrast to non-pathological anxiety, the worry in GAD is "pervasive, distressing and enduring" (Nutt et al., 2001, p. 12), causing interference in functioning and frequently accompanied by physical symptoms.

In sum, in all anxiety disorders life functioning and quality of life are impaired. Potential indicators of risk factors for adult anxiety disorders include: genetic factors, childhood psychopathology, temperamental factors, cognitive predispositions, behavioral tendencies, parental influences, life events, and peers. While urban living is not frequently mentioned in the context of anxiety, most research studies take place in an environment with a sufficiently large catchment area such as a city. As Gerzon (1997) indicates, we live in a culture that lacks models and methods to cope with even normal anxieties. He also posits a connection between anxiety, depression, and addictions, including substance abuse. When left untreated, anxiety can metastasize into distrust, alienation, anger, violence, and hopelessness.

Many persons who suffer from anxiety are reluctant to see a psychiatrist or psychologist due to cost or stigma. Being diagnosed with a mental illness can cause feelings of embarrassment, shame, and inferiority. Collins and Culbertson (2003) note that in the United States, the religious leader is often the first person people turn to in moments of crisis or upheaval, and they are often looking for strength, stability, and sympathy for their distress. It is interesting that several psychological studies have linked "intrinsic religiousness" with lowered anxiety (Sturgeon and Hamley, 1979; Baker and Gorsuch, 1982). For Allport and Ross (1960, 1967), intrinsic religiousness is characterized by "religion as a master motive" orientation that "interiorizes the total creed on [one's faith] without reservation." In contrast, extrinsic religiousness represents a utilitarian approach to religion that subordinates religion to other, non-religious goals such as comfort and social convention. Intrinsically religious persons, it could be said, integrate religious values into their world view and behavior. But here one needs to insert a caveat: what "type" of religiousness is being integrated into one's world view? As Pargament (1998,2007) has pointed out, not all "religiousness" is healthy. Is a strong belief in Satan, who lurks around every corner waiting to attack, adaptive in terms of reducing anxiety? We turn now to explore in more depth the role of spiritual strategies in treatment protocols for mood and anxiety disorders.