Understanding Anxiety: A Comprehensive Look at the Disorder
Just because an illness cannot be seen, does not mean it does not exist. While a physical illness often manifests itself in ways that are clearly visible such as coughing, sneezing or vomiting, the same cannot always be said for mental illnesses. People with mental illness can often put up a front, so much so that it is difficult to know that someone is battling an illness. According to Edlin & Golanty (2019), mental illness is “alternations in thinking, emotions, and/or intentional behaviors that produce psychological distress, medical illness, and/or impaired functioning” (p. 64). There are a multitude of mental illness that have been researched and defined over the past decades, including anxiety,
Anxiety is the most prevalent mental health disorder. Anxiety is a response to a future situation that is perceived as threatening, yet it has not actually happened and today, there are multiple types of anxiety disorders that have been defined (Edlin & Golanty, 2019, p. 73). While some worry is considered normal, constant worry and anxiety is considered a disorder, called generalized anxiety disorder (GAD). It is important to note that “in most anxiety disorders, patients usually process fear-inducing information in excessive detail that overwhelms their ability to appraise it properly. They cope by separating the information into good and bad with no gray area in between” (Bystritsky, Khalsa, Cameron & Schiffman, 2013, p. 32). This paper will provide a complete overview of anxiety from the history to present day, as well as terms, statistics and ways to treat the illness.
It is important to not confuse a normal amount of anxiety or fear with having a mental illness. To start, it is important to understand what it means to be mentally healthy, as well as its three components, before diving into what characterizes a mental illness. Edlin & Golanty (2019) provided a comprehensive view of mental health, which is “a state of mental well-being in which every individual realizes his or her own potential, can cope with the normal stressors of life, can work with productively and fruitfully, and is able to make a contribution to his or her community” (p. 64).
Being in a state of good mental and emotional health has three components: psychological, emotional and social, but when one of those components becomes irregulated or disturbed for a period of time, one might have a mental illness. Being mentally healthy means having a biologically healthy brain and nervous system and also interpreting the world realistically and being in sync with the environment. It is also important to note that mental health does not look the same for everyone, as Edlin & Golanty (2019) stated, “to be mentally healthy, we do not have to be like everyone else. Being true to ourselves leads to greater satisfaction in life than social conformity does” (p. 65). It is important that one understands the difference between anxiety and depression. Anxiety is characterized by persistent worry, whereas depression is a state in which a person experiences sadness, hopelessness, and a lack of motivation for a period of more than two weeks, and the feelings are so severe that activities that one enjoys while in their normal state are interfered with (Anxiety and Depression Association of America, n.d., para. 7). While many people are mentally healthy, the statistics surrounding anxiety disorders are staggering.
Nearly 1 out of every 5 adults in the United States experiences some type of mental illness in a given year. The exact percentage of people affected in a 2016 study was 18.5 percent of Americans, and nearly 1 of 25 adults in the country will experience a mental illness that interferes with one or more major activities (National Alliance on Mental Illness, 2016, para. 1-2). With a multitude of mental illnesses defined, anxiety is the most prevalent disorder. Anxiety disorders have been around for many years, but the extent of how common mental disorders are was revealed over 30 years ago. According to Bystritsky et al., (2013), “Anxiety disorders are present in up to 13.3% of individuals in the US and constitute the most prevalent subgroup of mental disorders” (p. 30). While anxiety is more common in adults than children and teenagers, that does mean that it does not exist among youngsters. Typically, when someone is diagnosed with a mental illness, it is commonly done when the individual is a teenager (age 14) or in their mid-20s. According to the NAMI (2016), “one-half of all chronic mental illness begins by the age 14; three-quarters by the age of 24 (para. 14). While these statistics focus on mental illness and anxiety in general, research has been done and statistics announced regarding anxiety in males vs. females and people in different walks of life.
From 2001-2003, the National Institute of Mental Health conducted a country-wide survey on mental illness (specifically anxiety) and released statistics regarding the prevalence of anxiety disorders. The study was done face-to-face in over a two-year period and had an initial response rate of 70.9 percent of households. The study was again updated in 2017. The NIHM stated that in an adult’s lifetime, 31.1 percent of adults living in the United States experienced some type of an anxiety disorder, but anxiety disorders were significantly more common in females. Among adults 18 years of age or older, the prevalence of an anxiety disorder was higher for females (23.4) compared to males (14.3 percent) (NIMH, 2017, para. 4). Listing the percentage of individuals with an anxiety disorder does not provide information on the severity of the disorder. Further research was conducted, and the data showed that the majority of anxiety disorders experienced by adults involved just mild or moderate impairment (77.2 percent), while slightly more than 1-of-5 individuals battled a serious anxiety disorder (22.8 percent). (NIMH, 2017, para. 7). Ultimately, although there is a high number of people battling anxiety, it is not something that has just become common, but has rather been battled for thousands of years, albeit with different terminology.
Dr. Marc Crocq in France compiled a comprehensive history of anxiety and stated that anxiety was at first believed to not have truly been an illness prior to 19th century, but today, that argument is becoming more and more invalid. According to Crocq (2015), “There are indications that anxiety was clearly identified as a distinct negative affect and as a separate disorder by Greco-Romano philosophy and physicians. In addition, ancient philosophy suggested treatments for anxiety that are not too far removed from today’s cognitive approaches (p. 320). Early philosophy focused heavily on fear, but both Stoics and Epicureans offered thoughts on anxiety.
Epicurius, a philosopher known for a school of thought called Epicureanism, believed that worry was a hindrance to living a happy life. Although Epicurius did not specifically use the term anxiety, it is clear that the philosopher was discussing it because of how in depth the writing mentioned being worry free. Today, persistent worry is one of the traits of anxiety. Epicruis believed that an individual needed to strive for a state known as ataraxia, where the person lived a life without worry (Crocq, 2015, p. 320). Epicurius’ writings were lost but seemed to lay the foundation for the discovery of anxiety, so to speak.
At one point, anxiety seemingly disappeared as a classified illness, although Crocq stated that patients with anxiety still existed, despite being diagnosed with other illnesses. However, in the early 1600s, Robert Burton discussed the idea of being melancholy and within that he mentioned anxiety. According to Crocq (2015), “Burton’s work is generally quoted in the context of depression. However, Burton was also concerned with anxiety. At that time, the meaning of melancholia was not limited to depression but also encompassed anxiety (p. 321). It could be argued that Burton laid the foundation for anxiety being classified as its own set of mental illnesses, although that would not happen for over one hundred years. In the 1700s, panic attacks became associated with melancholia, and anxiety was still under that same umbrella at the time. During that same century, Boisser de Sauvages published a French medical textbook, which contained ten different classes of diseases, with mental illnesses being defined under the eighth category (Crocq, 2015, p. 322). Despite de Sauvages work, which actually was the last medical textbook written in Latin, anxiety would not be at the forefront of the discussion until the late 1800s.
Physician George Miller Beard was one of the first individuals to involve anxiety as a component of a new disease category, including neurasthenia and neuroses. In 1869, Beard’s description of neurasthenia included anxiety and depression (Crocq, 2015, p. 322). Although Beard was among the first to include anxiety as a symptom, Sigmund Freud was the one who developed many of the terms for anxiety disorders, and those terms are still associated with anxiety disorders more than 150 years later (Crocq, 2015, p. 322). Fast forward to the 1950s when anxiety truly became a prevalent disorder. Why? Mental orders had their own publication – the Diagnostic and Statistical Manual of Mental Disorders.
The Diagnostics and Statistical Manual of Mental Disorders is referred to as DSM with a dash and roman numeral signifying the version. In DSM-I, a 1952 publication, anxiety went hand-in-hand with a psychoneurotic disorder because the chief symptom of a psychoneurotic disorder was anxiety (Crocq, 2015, p. 323). At the time, anxiety was associated with a dangerous or threatening situation. According to Crocq (2015), “anxiety in psychoneurotic disorders was interpreted as a danger signal sent and perceived by the conscious portion of the personality. It was supposedly produced by a threat from within the personality” (p. 323). To expand, coming from within the personality simply refers to impulses such as anger and hostility or emotions. Therefore, anxiety could be summarized as the reaction to a dangerous situation produced from one’s personality and manifested in the form of anger, hostility, resentment or extreme emotion. In the second version of DSM, neuroses were the main category in which anxiety disorders fell. Although it was associated with a category dealing with mental illness, major strides and expansion on anxiety disorders were not made until the start of a new decade in 1980.
With the publication of DSM-III in 1980, anxiety was placed in its own chapter and included several different types of disorders. While phobias were still included as anxiety disorders, anxiety states had its own classification with several sub-categories. The subcategories included types of anxiety that are commonly discussed and diagnosed today, including panic disorder, general anxiety disorder and obsessive-compulsive disorder (Crocq, 2015, p. 323). Additionally, a chapter was added for anxiety disorders in adolescents, rather than just focusing on adults. For children, three types of anxiety were referenced: separation anxiety disorder, avoidant disorder of childhood or adolescence, and overanxious disorder (Crocq, 2015, p. 323). Seven years later, DSM-III-R was published, and medical professionals were now able to diagnose anxiety without the diagnosis of depression along with it. Crocq (2015) summarized it saying, “…the most important change in the DSM-II-R (1987) classification of anxiety disorders was the elimination of the DSM-III hierarchy that had prevented the diagnosis of panic or any anxiety disorder if these occurred concurrently with a depressive disorder” (p. 324). Minor, if any, strides were made in the diagnosing and understanding of anxiety disorder in DSM-IV, but DSM-V, published less than six years ago in May of 2013, once again presented groundbreaking research for the classification of anxiety disorders.
DSM-5 grouped anxiety disorders that were in DSM-IV into three groups, anxiety, OCD, and trauma and stressor related disorders. This change in grouping was done because of the common features that each of the disorders shared, but significant medical research played a role. “For the first time, the increasing knowledge about the different brain circuits underlying stress, panic, obsessions, and compulsions played a role in classification … In addition, mixed anxiety-depressive disorder was not retained as a category in DSM-5 because, among other reasons, that diagnosis proved too unstable to follow up” (Crocq, 2015, p. 324). In the same year that DSM-5 was published, a group of physicians designed the ABC Model of Anxiety.
The ABC Model of Anxiety aims to help today’s physicians diagnosis the disorder. Through the years, the classifications of anxiety helped a physicians ability to diagnose anxiety disorders, while the goal of the model is to give patients a management tool. The ABC model is the idea that alarms (A), beliefs (B) and coping strategies (C) all interact together in space and can help explain anxiety. Bystritsky et al., (2013) said that understanding how those three things work together should lead to more precise diagnoses of anxiety and that although anxiety patients react to emotional situation (alarms) and develop a set of beliefs that coping strategies can help reduce anxiety (p. 31). This is an example of new approach to anxiety management that does not involve medication. Thankfully, due to adequate research and advances in medicine, there are a variety of ways to treat anxiety and ensure that a patient receive proper treatment.
Today, there are a multitude of options for patients requiring treatment for an anxiety disorder. From therapy to mindfulness to medications and lifestyle changes, anxiety disorders can be effectively managed and controlled so that the individual can live a successful lifestyle. It is of utmost importance, however, that the individual always consults a physician that is trustworthy before making any decisions regarding treatment of anxiety disorder.
When it comes to anxiety, there are a multitude of medicines that are used to treat the disorder. SSRIs (Selective Serotonin Reuptake Inhibitors) are typically the first group used. SSRIs include drugs such as Pfizer, Prozac, Paxil and Zoloft. The main thing that SSRIs do is increase the amount of serotonin in an individual’s brain. According to the Mayo Clinic (2018), “Serotonin is one of the chemical messengers (neurotransmitters) that carry signals between brain cells. SSRIs block the reabsorption (reuptake) of serotonin in the brain, making more serotonin available. SSRIs are called selective because the drug seems to primarily affect serotonin, not other neurotransmitters” (para. 2). SNRIs are another common medication used to help fight anxiety. Serotonin-norepinephrine reuptake inhibitors include Effexor and Cymbalta among others. SNRIs work to increase amounts of specific neurotransmitters in the brain. SNRIs get its name due to the fact that it increases serotonin and norepinephrine (Pittman, 2017, para. 3). SNRIs should not be used for short periods of time because the drug will actually increase anxiety when first used. Pittman (2017) said that individuals using SNRIs will typically see a change after 10 days and that the medication will work by promoting the brain’s neuroplasticity (para. 6). While these medications are often helpful, it is important that individuals receiving treatment for a mental disorder also understand the value of therapy, coping and lifestyle changes.
Commonly known as CBT, cognitive behavior therapy is not a medication that will make a patient feel less anxious but rather a method that focuses on the thoughts associated with anxiety. Cognitive behavior therapy “helps identify and then neutralize the thoughts that many trigger anxiety” (Harvard Health Publishing, 2017, para. 10). In CBT that is administered via a therapist, the patient is given strategies from a trained professional in an environment that fosters comfort and openness. The therapist will help the patient reduce the alarms and irrational thoughts or beliefs associated with their anxiety and cope with their situation (Bystritsky et al., 2013, p. 37). To be successful, a patient must use the strategies developed in consultation with the therapist to change their thought pattern. Edlin & Golanty (2019) mention that CBT is done to help people examine and change their thoughts that may specifically contribute to their anxiety (p.77). CBT takes time to become successful and often hinges on the patient’s ability to use the strategies present.
CBT can be paired with a medication such as an SSRI (Selective Seratonin Reuptake Inhibitor) or used alone in the treatment of anxiety. Bystritsky et al., (2013) fears that patients who self-administer CBT may not be effective and suggests that patients undergo CBT that is therapist directed (p. 37). One of the best things about Cognitive Behavioral Therapy is the clinical experience of physicians regarding the success of it. CBT has lower relapse rates compared to the use of medication alone because it is proven (through clinical observation) that it has a longer effect if the patient continues to use the strategies presented in therapy sessions (Bystristsky, 2013, p. 37). While CBT is one type of therapy used for the treatment of anxiety disorders, mindfulness and coping strategies are two other methods that do not require medicine.
In addition to medicine and therapy, one of the most popular ways that patients are encouraged to deal with anxiety battles is through the development of coping strategies and changing the train of thought associated with anxiety and situations that produce a feeling of distress. According to Edlin & Golanty (2019), “Coping strategies are ways to deal with the emotional distress that comes from not having your needs met” (p. 69). One of the ways that the duo suggest coping is by changing the thoughts of whatever is causing one anxiety. The authors also mention that an anxious person can avoid a situation, but their first suggestion was to “attack the situation head-on, saying, ‘I’m nervous about meeting new people, but I’ll go to the party anyway” (Edlin & Golanty, 2019, p. 69). One of the keys to successful coping is the ability to identify stressors. Physicians Karen Lawson and Sue Towey suggest that anxious individuals work to determine what causes stress and anxiety and work to not only reduce stress and relax, but also “cultivate resilience” so that individuals can handle stressors that arise and must be dealt with (i.e. are unavoidable) (Lawson & Towey, 2016, para. 12). While there are ways to cope, the biggest question is how an anxious person begins to effectively cope with their situation and mental disorder.
Therapy and support are two of the major ways that individuals with anxiety learn to develop coping strategies. Support is readily available from mental health professionals, including psychotherapists. “Psychotherapists are professionals who have undergone considerable training to help people deal with their emotional distress … A psychotherapist can facilitate change that makes a person’s life better. The change comes about not only by talking but also by helping the distressed person adopt new behaviors and attitudes” (Edlin & Golanty, 2019, p. 70). Along with medicine, therapy and learning to cope, certain lifestyle changes are recommended for individuals who battle anxiety.
One of the most important things for an individual with an anxiety disorder is to get an adequate amount of exercise. Exercise might be the place to begin if a person with anxiety is looking to become healthier. Research shows that exercise helps improve anxiety symptoms, and there is science to back it up. While exercise can help someone gain self-esteem or confidence, “exercise stimulates the body to produce serotonin and endorphins, which are chemicals in the brain (neurotransmitters)” (Lawson & Towey, 2016, para. 2). In addition to exercise, diet changes are a key component for someone who is looking to overcome anxiety. From abstaining from alcohol and cutting out sweet drinks such as soda or tea, it is important that an individual with an anxiety disorder fuel their body properly. Lawson & Towey (2016) recommend plenty of water and calcium and a reduction of fats to properly fuel one’s body and help the brain to work. “The brain is one of the most metabolically active parts of the body and needs a stream of nutrients to function. A poor diet may not provide the nutrients necessary to produce neurotransmitters and may provoke symptoms of anxiety or depression.” (para. 5).
When it comes to finding a therapist, physician or support group, there are many options and different medical professionals with a unique specialization. One place for an individual seeking help for anxiety is the “Find a Therapist” Directory on the Anxiety and Depression Association of America website. The list is by no means exhaustive and includes only physicians with a desire to be included, but has doctors who specialize in anxiety, depression, OCD and PTSD. Additionally, the National Alliance on Mental Health has an entire section of its website devoted to support. The NAMI focuses not on support groups or therapy but support that friends and family members can offer. The website deals with help, preparation for what could happen during a crisis and recovery.
Healthypeople.gov, which is run by the United States Department of Health and Human Services, has provided a list of comprehensive objectives regarding a variety of mental disorder. The majority of objectives related to anxiety (i.e. not dealing with depression alone) deal with treatment of the disorder. Shockingly in 2006, only 79.0 percent of primary care facilities were able to provide mental health treatment to individuals in need or to give a referral (US Department of Health and Human Services, 2019, para. 6). Seeing that the number was low, the Department of Health and Human Services has set a goal of improvement (see MHMD-5), so that nearly 9 out of every 10 primary care doctors’ offices can provide treatment for anxiety in office or provide a referral.
Going beyond the fact that facilities need to either treat individuals with a mental health disorder or provide a referral, a goal of Healthy People 2020 is to see an increase in people receiving treatment if it is needed, regardless of whether the individual is an adolescent or adult. A maximum of 10 percent improvement has been set as the standard for the increase in people receiving proper treatment (US Department of Health and Human Services, 2019, para. 7,10). MHMD-6 noted that of the children diagnosed with a mental disorder, only 68.9 percent received the necessary help when statistics were taken in 2008, but the goal for 2020 is for 75.8 percent to receive treatment.
For adults 18 and older (MHMD-9), the percentage of those obtaining proper treatment was even lower than children. The baseline year (2008) showed that only 6.5 out of 10 individuals battling a serious received treatment, but in 2020, it is hoped that 72.3 percent of affected individuals will receive treatment (US Department of Health and Human Services, 2019, para. 10). While treatment for a mental health disorder is important, it is equally important that individuals are able to carry out a normal lifestyle as much as possible.
The last objective related to anxiety dealt with increasing the employment rate of individuals battling a serious mental disorder (MHMD-8). 12 years ago, only 56 percent of people with a serious mental illness were employed (US Department of Health and Human Services, 2019, para. 9). The goal for 2020 is to increase that number by 5.1 percent and see 61.6 percent of affected individuals employed.
If strides continue to be made, there is an opportunity for the stigma surrounding mental illness to be eliminated. The majority of the objectives presented on healthypeople.org had a desired increase of five to seven percent. If a seven percent increase happens three times in the next 36 years, then healthypeople.gov will have objectives to see all facilities treating mental health disorders or offering a referral. Additionally, the target percentage for children receiving treatment for children and adults would both be above 90 percent.
Mental illness are present in millions of individuals worldwide, including the United States. The illness might not always be seen because its symptoms can be hidden or masked, unlike a physical illness such as the flu or cancer. While anxiety is just one of multiple mental disorders, it is incredibly prevalent, today. Normal amounts of anxiety arise in people, but when the levels get beyond normal and begin to interfere with normal life activities, a person is said to have anxiety disorder. According to Reynolds (2014), anxiety can be incredibly expensive to treat, with costs being in excess of $78 million in total annually or $2,700 per patient (p. 2). However, despite the cost, there is hope for those battling anxiety as social support groups, coping, therapy and even medication can help someone live a successful life. Although the illness might never be able to be completely eradicated, it is possible to treat it. Once an individual recognizes that treatment is needed and discusses the proper path to management, the path to living a better life has begun. Through a variety of treatment options and a never quit attitude by the United States Department of Health and Human Services to provide better treatment for anxiety, the disease has become manageable.
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