By Dr. Elaine Kindle -

Sara (These stories are based on actual people. A few facts have been changed to protect their anonymity.)breathed in the cool fresh air. Her car smoothed along the open corridors of Highway 395. White yellow early morningsunlight poured through open windows. She felt the serenity and peacefulness of this wondrous break of day. Shenoticed how the sky sat like an upside-down blue bowl seeming to encapsulate the mountainous landscape. She heardthe birds' songs bounce from the trees, reverberating and intensifying their orchestral warmup. She relaxed behindthe wheel, as she drove back to school after her Spring break in the Sierras. It was good to have time alone. Shehoped that this, the last and final semester of graduate school, would pass quickly. Suddenly, out-of-nowhere,she felt "It". Tingling slowly began in her left fingertips. She shook her hand and continuedto drive. But the tingling persisted, and crawled, like a spider, from her wrist, up her arm, onto her neck andinto the left side of her face. Sara's heart raced. She never experienced anything like it before. She prided herselfon her good health, especially since all the adults in her family had had heart attacks or strokes. "Ohmy God, I'm having a stroke. Here I am miles from home and civilization, all alone. No one will find me. I won'tbe able to finish school; there goes my dream of a Master's, a good job. I'll be dead or deformed..." Panicked,she pulled off the highway into a rest area. "What should I do? Who can help me? What if no one is around?What if I ask someone and I end up getting robbed?" By now, Sara's entire left arm and face were numb.She stopped the car and just sat there, chest pounding, feeling lightheaded and more scared than she could everremember. She breathed deeply, trying to calm herself. And then, slowly she noticed the numbness started to disappear.Checking herself, she moved her hand across her face, prodding and poking, then down her left arm squeezing itfrom top to bottom. It had sensation. Then she shook her left hand and rubbed her fingers together. The numbnesswas gone. Shaken, she carefully continued the drive home. She didn't know what happened to her, and tried to putit out of her mind. Years later, following similar instances, Sara would begin to understand what had taken place,that she had had a Panic Attack. But for now, the journey was frightening.

Sara's story is real. She is one of the millions of Americans who experience anxiety.Statistics state that 20 - 37 million Americans suffer from anxiety of some type. The estimate of 20 million meansthat 1 in 9 people have some problem with anxiety!

Not everyone who experiences symptoms of anxiety has a panic attack, nor even an anxiety disorder. Anxiety,in and of itself, is a normal emotion. All of us have had times when we feel anxious. Sometimes the anxietymay even be helpful to us by prodding us to complete some task. Excess and intense anxiety over time, however,creates a problem. It throws us off balance, disrupts our lives, and creates chaos, or a lack of order. It is thisexcessive anxiety that defines anxiety disorders as outlined in the current manual mental health professionalsuse, known as the DSM- IV. On the other hand, persons like Sara who have panic attacks can develop panic disorder.

Sara's symptoms were intense and seemed to come out-of-the-blue. She didn't know it, but she had had a panicattack. Her symptoms included heart palpitations, sweating, numbness and tingling in her extremities,lightheadedness, trembling and fear of dying.

What is anxiety?

In its simplest definition, anxiety is "worry or uneasiness about what may happen," or "a tenseemotional state". However, all of us experience some anxiety. Some anxiety is part of our everyday lives,and at times may even help us to accomplish tasks. However, too much anxiety, intensely felt over time is a problem.Anxiety affects our whole beings - body, mind, spirit. It affects us physiologically & behaviorally,psychologically, and spiritually.

Physiologically: physical symptoms may include: tension, sweating, heart palpitations, increased heartrate, dry mouth, stomach/gastrointestinal distress.

Behaviorally: anxiety can sabotage our actions, affect our speech, or even our memory.

Psychologically & spiritually: we feel apprehensive, distressed, we may fear we are goingcrazy. We may even feel some amount of detachment, or think we're going to die.

How does Anxiety differ from Stress?

Hans Seyle, the father of stress research, says stress occurs when "our body responds to a demand in anonspecific way". What does that mean? Simply put, when we experience any stressor, our bodies' balance/equilibriumgets shaken up and we react. Something can happen, and we respond to it. The response may or may not have anxietyattached to it. For example, Ron, a fire fighter, worked on the team putting out major brush fires. His body becametired during his long hours on the line, but he did not feel emotionally anxious. On the other hand, cumulativestress over time can lead to the development of an anxiety disorder.

What is an Anxiety Disorder?

If anxiety is a tense emotional state, when taken to the extreme, it may develop into an anxiety disorder. Intensephysical reactions often coexist together with anxiety. Anxiety disorders create chaos and disruption in our lives,and can create dysfunction or debilitation.

Overall, anxiety disorders differ from anxiety in three basic ways:

• intensity: they are more intense that normal anxiety
• duration: the anxiety persists even after a stressful situation has passed
• complications: they may lead to phobias that further interfere with life

How does Anxiety Differ from Fear?

Anxiety and fear often are used as synonyms. Technically, there is a difference. The word "anxiety"comes from the Latin word "anxius", which meant a condition of agitation and distress.The stem of anxious - anx - comes from another Latin word, "angere" which means "tochoke" or "to strangle" which describes one of the symptoms of anxiety which some people experience.

The word "fear" comes from the Old English word "faer", which meant "suddencalamity or danger". Currently the definition includes the possibility that something dreaded or unwantedmay occur.

In essence, anxiety is an emotional process; fear is a cognitive one.

Causes of Anxiety Disorders

Basically, four factors create anxiety disorders: genetics/heredity; brain chemistry; life experiences/triggers;and personality type/maintaining causes.

• Genetics/heredity
  Anxiety tends to run in families. If our mother or father was anxious, some of that anxiety may have been passedon to us in our gene pool.
  
  
• Brain chemistry
  Our brain fires certain amounts of brain chemicals needed to keep us balanced emotionally. When these brainchemicals are not firing correctly, or are lacking, various emotional disorders can occur, such as anxiety, depression,explosive anger, and severe mental illness.
  
  
• Life experiences/triggers
  All of us have various circumstances happen in the course of our lifetime that produce stress and anxiety. Harsh,critical, perfectionistic upbringings can serve as triggers to the development of anxiety disorders. Negative environments,extreme ongoing stress, or crises events that traumatize us also can lead to the onset of anxiety. If we have poorcoping skills or if our self-esteem is low we are more prone to develop anxiety disorders.
  
  
• Personality type/maintaining causes
  Our personality type develops as a result of many factors, including genetics, and our environment, or nature/nurture.This includes our support systems, our resultant sense of worthiness, and experiencing successes that are importantto us (components of self-esteem).

Some thoughts/behaviors that maintain or fuel anxiety are:

• anxious and negative self-talk
• mistaken beliefs we hold about ourselves or others who are important to us lack of self-nurturing skills
• avoiding situations that make us anxious, hence developing phobias
• withholding feelings (or revealing them to the "wrong" persons or in an ineffective way)
• poor communication skills, including lack of assertiveness
• having found no meaning or purpose to life

Prevalence:

In general, most personality disorders tend to be more prevalent in women than in men. Considering the historical"back-seat" role women have taken to men may be one of the reasons why this is so.

Typically, panic attacks begin in late adolescence through the mid-30s. Sometimes, children can experience panicattacks, or individuals over 45 can have a first panic attack.

Individuals who suffer from an anxiety disorder often experience more than one anxiety disorder.Additionally, anxiety often provokes depression. Some people try to self-medicate anxiety through food, drugs,or alcohol. Consequently, they may develop substance-related disorders and/or eating disorders.Since the anxiety and food or substance disorders have a relationship to one other, sometimes it is the substancedisorder that provokes the anxiety.

What is a Panic Attack?

A panic attack is a discrete period of time during which there is a sudden onset of intense fearfulness, terror,apprehension, often accompanied with feelings of impending doom.

Symptoms of Panic Attacks:

If a person has an anxiety attack, that individual experiences intense discomfort or fear for a time combinedwith at least four of the following 13 symptoms identified in the DSM IV:

• palpitations, pounding heart, or accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, lightheaded or faint
• derealization (feelings of unreality) or depersonalization (being detached from self)
• fear of losing control or going crazy
• fear of dying
• paresthesias (numbness or tingling sensations)
• chills or hot flushes

Full & Limited-Symptom Attacks:

Panic attacks can be "full" like Sara's, or what's known as "limited symptom" attacks. Inlimited- symptom attacks, a person experiences less than four of the thirteen symptoms outlined above.

What's the Difference between Panic Attacks and Panic Disorder?

In a word, quantity characterizes the difference. When a person experiences more than one panicattack, the diagnosis becomes Panic Disorder. Remember, a key component of a panic attack is a sudden episode ofintense fear or apprehension that seems to come "out-of-the-blue". Intense panic usually lasts only afew minutes, but in some cases, can return in "wave-sets" lasting up to two hours.

What is Agoraphobia?

The word "agoraphobia" means fear of open spaces. The essence of agoraphobia is afear of panic attacks [that might occur in open, hence unsafe, spaces].

Therefore, Agoraphobia is anxiety about being in places or situations from which escape might be difficult orembarrassing, or in which no help may be available should a panic attack happen. Agoraphobia is best known as fearof going outside the home, but its definition is more inclusive. A person with agoraphobia might fear being ina crowd, traveling in a car, or by mass transit, driving freeways, shopping, or may be afraid of standing in line.Again, that person is are not fearful of these things inherently, but rather the fear is about the possibilityof having a panic attack while in these places.

People with agoraphobia develop this problem not only due to heredity and environment, but from a combinationof factors. People who develop agoraphobia may be fearful of being in strange places, or may be overly dependenton a caretaker to help him/her cope with this problem, or they may interpret their internal sensations as signsof severe pathology.

Types of Anxiety Disorders

Panic Disorder with Agoraphobia:

Sara experienced a panic attack. If she had recurrent, unexpected panic attacks, she would be considered ashaving Panic Disorder. In addition, if her panic attacks caused her to worry for at least a monthabout having further panic attacks, or if her panic attacks led her to avoid situations that might create furtheranxiety, Sara's Panic Disorder would be complicated by Agoraphobia. Approximately 1/3to 1/2 of individuals diagnosed with Panic Disorder also have Agoraphobia.

Panic Disorder without Agoraphobia:

If Sara did not experience additional fears/behaviors together with recurrent unexpected panic attacks, herPanic Disorder would not include the diagnosis of Agoraphobia.

Agoraphobia Without History of Panic Disorder:

Agoraphobia occurs in context of an anxiety disorder of some type. The anxiety disorder may or may not includepanic disorder. Therefore, while a person can have Panic Disorder that includes Agoraphobia or not, it also ispossible for a person to have Agoraphobia without Panic Disorder. In this case, the person fears the occurrenceof incapacitating or extremely embarrassing panic-like symptoms or limited symptom attacks rather than full PanicAttacks. However, 95% of people with Agoraphobia also have had Panic Disorder at some point intheir lives.

Types of Panic Attacks:

There are three types of panic attacks - those that are:

• unexpected
• situationally bound
• situationally predisposed

What does this mean? Unexpected attacks are those that come "out-of-the-blue". The other two types,situationally bound and situationally predisposed, occur within the context of other phobias, specifically, SocialPhobia, which is cued by social situations; Specific Phobia, which is cued by an objector situation; Obsessive Compulsive Disorder (OCD), which is cued to exposure to the object ofan obsession; or Post Traumatic Stress Syndrome (PTSD), which is cued to stimuli recalling thestressor.

Let's take a closer look at each of these disorders.

Social Phobia:

Ruth was nervous about giving a presentation at work. She worried that her hands would shake, her face wouldget red, and she would stumble over her words. Ruth's form of anxiety came out in a different way than Sara's.Ruth feared speaking in front of people, especially people who might criticize, embarrass, or ridiculeher. Although Ruth knew in her mind that this fear was irrational, she couldn't calmher emotions. She felt her life was becoming disrupted by her reaction to the upcoming presentation.She refused to go to lunch with her friends because she had to work on her talk. She stayed late at work becauseshe had to generate computer graphics. She thought of calling in sick on the day of her presentation, but felther job would be on the line if she did so. Rather, she showed up on that day, and despite a rock in her stomach,and her knees feeling like someone on board a ship, she anxiously endured her presentation.

Ruth's anxiety fits the category referred to as social anxiety, or Social Phobia. Like Ruth,people with Social Phobia fear giving a performance of some type, or even of attending a social event which makesthem fearful of being embarrassed, ridiculed, or looking inadequate. Social Phobia is one of the most common anxietydisorders. In addition to social anxieties, Social Phobia includes: fear of public-speaking (the most common fearpeople have); fear of blushing in front of others; test anxiety; fear of eating in public (spilling food whileothers are watching); fear of choking on food; fear of being watched at work; fear of using public toilets; fearof crowds; fear of writing or signing documents in the presence of others.

The bottom line of each of these fears is that of scrutiny - of having one's ability evaluatedby others and judged as inferior.

A panic attack related to this fear also may occur.

Social phobia tends to be experienced equally between men and women. It tends to first appear in mid-teens,and sometimes follows a history of childhood shyness.

Specific or Simple Phobia:

Unlike Ruth, some people may have no trouble giving presentations or attending social events, but let a spidercross their path, or if they have to get on an elevator, or get an injection, and they become terrified. This groupof people who fear objects, or situations, begin avoiding the things they fear. They may developwhat's known as Specific or Simple Phobia.

James was one of these persons. A CEO of a Fortune 500 company, James always was at work before anyone else,and left last in the evening. He tended to host meetings and luncheons in his office rather than at a restaurant.What James didn't want anyone to know was his intense fear of riding in elevators.Each morning and each evening, although he knew his behavior was unreasonable, he faced the taskof climbing the 15 flights of stairs to his office. If anyone did see him, he pretended his climb was part of hiswork-out routine.

Other examples of Specific Phobia include: animal phobias (including spiders and snakes); fear of flying; fearof going to the doctor or dentist; fear of heights; fear of thunder and/or lightening; fear of injections; fearof blood....

Specific phobias tend to begin in early childhood. For example, people may develop phobias as a result of neveroutgrowing a childhood fear. Since children tend to copy or model their parents' behavior, if their parents havea Simple Phobia, children can develop this fear as well. Other persons may develop phobias following a traumaticevent they witnessed or experienced.

On the whole, women experience Simple Phobias to a greater degree than men.

Obsessive Compulsive Disorder (OCD):

Anyone who read Shakespeare's Lady Macbeth in school remembers what is included in this anxiety disorder. "Out,out damn spot," refers to Lady Macbeth's compulsive behavior after committing murder.

Alicia hadn't killed anyone, but she reacted to herself in as strange a way as did Lady Macbeth. Her fear wasmuch too frightening to talk about with another person. She didn't want anyone to know what a bad person she was.She looked at herself again and again in front of the mirror. "I'm an evil person," she said to the imagebefore her. "I'm a horrible mother." Alicia had once again imagined herself chocking her two childrento death and stuffing their bodies in the closet. She felt overpowered by this recurring intrusive imageand nothing she could do would get it out of her mind. It didn't make sense to her because she loved herchildren. In her quiet desperation, she developed a ritual for herself that gave her a sense ofcontrol. She stood in front of the mirror, hour after hour, chanting a little rhyme, "As long as I don't lookuptight, I know my kids will be all right, as long as I don't look uptight, I know my kids will be all right..."

Alicia created a ritual or behavior for herself that she compulsively performedin order to control her unremitting obsessive thoughts about harming her children. Alicia had Obsessive-CompulsiveDisorder (OCD). People with this disorder have consistent fearful uncontrollable thoughts (obsessions)that they try to manage through repetitive behaviors that often take on a ritualistic form (compulsions).Examples of obsessions include images of violence such as those experienced by Alicia. In addition, obsessionsinclude fears such as fear of leaving the lights on, or the stove on, or fear that you didn't lock your door. Compulsionsstem from the obsessions. These compulsive behaviors or rituals, like Alicia's, are attempts to dispel the anxietycreated by the obsession. For example, a person can continue to look in the rear view mirror, or to drive up anddown the same street over and over again, in an effort to check on and calms fears about not hitting anybody whiledriving.

People with OCD often experience depression or phobic avoidance as well.

Post Traumatic Stress Syndrome (PTSD):

Matthew, a 6'2" husky paramedic, loved his job. He especially thrived on helping people who had lost theirhomes during Natural Disasters, as he found this work rewarding and meaningful. During one rescue, he came acrosssome unexpected casualties. Suddenly seeing their bodies twisted among the crumbled ruins left him with nightmares,exaggerated startle responses, and recurring intrusive thoughts of the horror he had witnessed. Thesesymptoms lasted for more than a month. Consequently, Matthew was diagnosed as suffering from Post-TraumaticStress Syndrome (PTSD).

People became aware of PTSD for the first time following World War I. After this War, soldiers suffered chronicanxiety, nightmares, startle responses, and flashbacks that lasted not only for weeks and months, but also foryears following combat. This syndrome originally was known as "Shell Shock".

Events that may cause individuals (or groups of people) to develop PTSD include war, natural disasters (suchas earthquakes or tornadoes), rape, abuse, and serious accidents (such as car or plane crashes).

Persons can experience PTSD not only from personal experience but also from witnessing a violent or tragic event.When people witness these horrendous events, they experience secondary trauma, such as Matthew did.

Persons who experience or witness these type events differ from common responses insofar as they continuallyre-experience the event over and again. This re-experience may come out in nightmares, flashbacks, or hallucinations.

Persons with PTSD often avoid anything associated with the event. They may seem detached or they may have increasedarousal such as irritability, extreme alertness, difficulty sleeping or concentrating, or being jumpy. It's obviousto understand, then, that PTSD affects functioning in these individuals. They find that they can no longer performin the same manner as they did prior to the traumatic happening.

Acute Stress Disorder:

Acute Stress Disorder and PTSD are similar in nature. A main difference between Acute Stress Disorder and PTSDis the time factor involved. Symptoms are similar for both. A second difference between the twois that persons with Acute Stress Disorder may experience a greater degree of detachment, or disassociationthan persons with PTSD.

Generalized Anxiety Disorder (GAD):

Some people aren't afraid of just one thing, they are afraid of just about anything and everything.Connie was one such person. Her family called her a "worry wart". She worried regardless of what wasgoing on. If things were going well for everyone, she worried that something bad would happen. If things were notgoing so well, she worried that even worse things would happen. When she decided to return to school for an MBAafter she had been working for the same secure company for ten years, she worried even more. Although she wantedto advance in that company, had good evaluations from them, and had done well in college, she worried about losingher job, failing classes, getting sick and not being able to take finals. Then she worried that her husband wouldget tired of her complaining and leave her, or her kids would get in trouble without her being there and on andon. She worried that she might need to miss work, and that her salary would suffer from those absences. Conniewas a jumble of nerves, and found it quite impossible to control her fears. She experienced what's known as GeneralizedAnxiety Disorder, or GAD.

Symptoms of GAD include excessive anxiety and worry more days than not about two or more of everyday life situations,such as Connie did. Connie worried about school and work performance (in spite of evidence to the contrary), sheworried about her family, she worried about finances. In GAD worry persists for more than six months. It is notaccompanied by panic attacks, phobias or obsession. High anxiety levels create complications in individual's lives,whether at work or at home.

Persons with GAD have a host of accompanying physical sensations as well:fatigue, edginess, irritability, sleep disturbance, difficulty concentrating, and muscle tension.

Other Anxiety Disorders:

Other Anxiety Disorders are those due:

-- to a general medical condition or

-- to substance abuse

Another kind of anxiety disorder is categorized for individuals who experience some of the symptomsof particular anxiety disorders are present, but not enough to meet the criteria needed for a diagnosis. They arereferred to as "NOS" or not otherwise specified.

Other Disorders Related to Anxiety:

There are four other types of disorders that have a relationship to anxiety. They are:

1. Body Dysmorphic Disorder: In this disorder, a person is preoccupied with an imagineddefect in his or her appearance.

2. Hypochondriasis: This disorder involves the fear of having a serious illness inthe absence of an identified medical condition.

3. Skin Picking: People with this disorder repetitively pick their own skin whichresults in damaging their skin.

4. Trichotillomania: In this situation, people continually pull out their hairwhich results in noticeable hair loss.

Summary

Anxiety is a normal part of life all of us experience at times. Genetics and environment work which may causeexcess stress and anxiety in our lives are two contributors to the creation of anxiety disorders. Some anxietydisorders may be accompanied by the additional burden of panic attacks or agoraphobia. However, it is possibleto control our anxiety. Bringing anxiety under control does take work, and does take practice. Some days we willbe able to handle our anxiety more effectively than others, but on the whole, we do not have to give in to ouranxiety.

Techniques and therapeutic methods have been developed over recent years which help us to contain our anxiety.Some techniques we can learn on our own; therapeutic methods include the involvement of a therapist trained inanxiety disorders. When we can have more control over understanding and coping with our anxiety, we can have moreproductive and enjoyable lives.

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