Читать книгу Ten Steps to Relieve Anxiety - H. Michael Zal - Страница 10

Introduction

Forty million adults suffer from anxiety disorders in the United States today. Of this, 6.8 million people have generalized anxiety disorder (GAD), which is our most common mental health problem. GAD is an inherited biological illness that may run in families. It is second only to major depressive disorder in lifetime frequency. Chronic anxiety can be demoralizing, limit your life and interfere with your ability to function. It may grow worse when you are under stress. Its clinical manifestations have great social, medical and economic consequences (most of the costs result from reduced or lost productivity).

Søren Kierkegaard, the founder of existentialism, first described anxiety in his 1844 book, The Concept of Anxiety. He believed that the freedom to choose without guarantees about the correct choice caused dread and anxiety.¹ His colleagues Karl Jaspers, Martin Heidegger and Jean-Paul Sartre also agreed that man’s freedom to make choices is the source of his anxiety.² Jacob Mendes Da Costa noted the frequent association between chest pain and anxiety in soldiers who were upset by their experiences in the American Civil War.³ His article, “On Irritable Heart…,” published in 1871 in the American Journal of Medical Sciences, highlighted this connection. During the next hundred years, anxiety had a number of aliases, underlying the cardiac manifestations of anxiety. These labels changed after each major war. Cardiac Neurosis (Da Costa’s Syndrome) became “neurasthenia” during World War I. World War II brought the term “anxiety state.”

Sigmund Freud stripped away the emphasis on physical symptoms to lay bare a theoretical skeleton emphasizing emotional components. He saw anxiety as one of the keys to understanding human dynamics and coined the phrase “anxiety neurosis.”⁴ Psychoanalysis sees anxiety as a signal that certain unacceptable impulses (sexual or aggressive feelings) are trying to escape the unconscious and are trying to break into consciousness. Mental pain serves as a signal to mobilize other defense mechanisms to try and keep this material out of awareness. These unacceptable urges can be real or symbolic.⁵

A more modern view concentrates on the biological causes of anxiety. It involves three neurotransmitters, or hormone substances, that cause a nerve impulse to move from one nerve cell to another. They are gammaaminobutyric acid (GABA), serotonin and norepinephrine. Particular emphasis is placed on the GABA system not working properly. GABA acts as an internally produced tranquilizer that decreases anxiety. People with GAD may have low levels of this naturally produced hormone.

Positron emission tomography (PET scan), which examines chemical changes in brain tissue, has shown that the neurotransmitters serotonin and norepinephrine also play a role in anxiety regulation. The discovery that these three hormones, or neurotransmitter systems, are involved in anxiety disorders allows us to recognize them as real biological conditions and true medical illnesses.

Anxiety is a universal feeling. To a moderate degree, anxiety has various positive aspects and can be considered “normal.” It can serve as a biological warning system that is activated during times of potential danger or threat. It can prepare a person for an exam, speech or battle. It can increase alertness and effort and enhance your performance. It is the rapid beating of your heart as you await big news. It is the restless tension that you feel prior to taking a test or giving a business presentation. It is the worry that a parent experiences listening for a teenager to return home after their first solo car drive. It is the feeling of impending doom inherent in answering the boss’s call. It can be conducive to learning and growth.

If these feelings become free-floating and increase in frequency and intensity, you have crossed the line from “normal” to “abnormal” anxiety. “Abnormal,” or nonadaptive, anxiety is more severe, interferes with functioning and with your capacity to experience satisfaction or pleasure. These more persistent levels of anxiety can cause disorganization, impair concentration, create uncomfortable physical symptoms, disturb sleep and precipitate depression and fatigue.

At our first meeting I usually recognize anxiety clients because very often they come early for their appointments. Once they are seated in the treatment room, their tension flows across my desk in waves. By the end of the session, I am feeling their stress.

“Have you generally been nervous all of your adult life?” is one of the key questions that I ask if I suspect that I am dealing with an anxious person and I want to quickly narrow the diagnostic field and rule in GAD. Besides free-floating anxiety, nervous people show three other cardinal features: avoidance behavior, excessive unrealistic worry and vague physical complaints. Anxious people often also complain of fatigue, headache, insomnia and abdominal or chest pain. The degree of disability may vary. The course is chronic and variable. Symptoms often intensify during times of stress.

THE TRIAD OF ANXIETY

The three features shown above, along with free-floating anxiety, are the cardinal characteristics of GAD. It is the most common of the anxiety disorders. To be diagnosed with this problem you must suffer from excessive anxiety and worry for at least six months in reference to a number of issues. The worry is difficult to control. The symptoms cause significant distress or impairment of functioning. The complaints are not due to the use of a substance, medical condition or other psychiatric disorder. You must show at least three other emotional or physical signs and symptoms of anxiety. These symptoms often result in significant emotional pain and prevent you from relaxing and enjoying life. Your anxiety can show in many ways:

Emotional Aspects of Anxiety

Feeling tense, keyed up or restless

Irritability

Apprehension

Excessive worrying

Feeling suddenly scared for no reason

Fear of heights, darkness or being alone

Social fears

Sexual worries

Fear of death or having a serious disease

Feeling panicky

Derealization (out of body experience)

Fear of losing control or going crazy

Feeling that something terrible is going to happen

Physical Aspects of Anxiety

CARDIOVASCULAR

Palpitations

Dizziness

Faintness or lightheadedness

Chest pain or pressure

RESPIRATORY

Shortness of breath

Hyperventilation

Choking sensation or lump in the throat

MUSCULAR

Muscle tension

Easy fatigability

Trembling/shaking

Weakness

Rubbery or “jelly legs”

GASTROINTESTINAL

Dry mouth

Indigestion

Nausea and vomiting

Butterflies in stomach

Diarrhea

Flatulence

OTHER

Sweating/hot flashes or chills

Headache

Constant urge to urinate

Numbness or tingling sensation

Spells of increased sensitivity to sound, light or touch

Difficulty in concentration/mind goes blank

Sleep disturbance

Exaggerated startle response

Skin disorders

Your physician or psychiatrist needs to rule out other emotional and physical disorders and rule in other overlapping, or comorbid, conditions. Individuals with a normal reaction to stress, major depression, personality disorders or those withdrawing from substance abuse or dependency can show anxiety. Anxiety can also be seen in acute psychosis and schizophrenia. People suffering from hyperthyroidism, hypertension, cardiac arrhythmias or mitral valve prolapse can all come in the door complaining of anxiety. Various medical disorders such as irritable bowel syndrome, asthma/chronic obstructive pulmonary disease (COPD) and pheochromocytoma, a hormone-producing tumor, can overlap with anxiety symptoms.

Generalized anxiety disorder clients may also suffer from other anxiety disorders such as obsessive-compulsive disorder (OCD), social phobia, post-traumatic stress disorder (PTSD) and panic disorder. Your doctor initially needs to decide if your complaints are emotional, physical or both. To decide this, we need to take a good health history, check all of your medications, question you about drug use or abuse and look at basic bloodwork. I usually ask for at least a complete blood count (CBC and Differential), comprehensive metabolic panel and thyroid profile (thyroid stimulating hormone [TSH], T3, T4). Therapists often may have to talk to your current and previous physicians. If you are diabetic, we may need to follow your glucose and HbA1C numbers. Fluctuations in your sugar levels can affect your mood. At times, a testosterone level may be helpful in men to differentiate between low energy due to anxiety and physical issues. Being given a specific diagnosis can give relief and even reassurance to some people. As they exhale, they often say, “You mean that all I have is anxiety? I thought that I was going crazy.”

Anxiety is possible throughout the life cycle. It can hide within shy, inhibited children and adolescents in crisis. It can appear in young adults expanding their social and vocational options and can accompany the shattered expectations of midlife. GAD may actually be the prevalent mental disorder in the elderly. It is sometimes difficult to diagnose in this age group. Their bodily complaints and sleep problems can signify anxiety. Depression, dementia and even substance abuse can mask and/or produce anxiety symptoms. Primary medical problems as well as medication can also cause their anxiety. Studies have shown that GAD (affecting 7 percent of seniors) is more common in the elderly than depression, which affects about 3 percent of seniors.⁶

GAD is common, chronic and disabling. It is a real biological illness that is treatable. It is not a form of hypochondria or a sign of weakness. It usually presents with the four cardinal features noted earlier but can often present with physical complaints alone. Treatment options include education and reassurance, psychotherapy, cognitive-behavioral therapy (CBT), pharmacology, relaxation/meditation/biofeedback, exercise and diet. Spirituality is helpful to many. You must conquer the cycle of fear and reduce cognitive distortion. Thoughts such as “something terrible is going to happen” and “I am going to lose control” can escalate anxiety and fear. Try to interpret these feelings to simply mean “I am feeling nervous.”

Managed care has marginalized many psychiatrists into just doing medication management. One of the biggest and most important changes during my long psychiatric career is the growth in the field of psychopharmacology and the benefits of psychiatric medication. However, there is no “magic pill” to solve all of your emotional problems. Psychiatric training is now moving toward a return to teaching residents and fellows to conduct therapy.

This book was written from my vantage point as a clinician working with real people. I provide both therapy and medication management. I feel that they are both important in obtaining relief from emotional distress. I take an eclectic but old-fashioned approach and offer individualized treatment suggestions that put the emphasis on the whole person. I will discuss conventional as well as alternative therapies. Many options will be offered.

Unlike many books that promise a cure, this one will present a more realistic picture of what treatment can accomplish for you. An appropriate expectation of psychiatric treatment is that it can offer education, reassurance, symptom reduction and control, teach coping mechanisms and ways to feel more in control, foster perspective and insight about the past and present and encourage growth and maturity. A positive therapist-client relationship is a strong therapeutic tool. A connection with your therapist can allow you to feel secure while you are learning to deal with your anxiety.

Therapy can help you understand yourself better and often can give you the support, encouragement and acceptance that you did not receive when you were young. Your parents may not have been able to give you everything you wanted emotionally, because their own parents may have been limited. Therapy cannot totally make up for the things that you did not obtain in childhood. It cannot completely fill or reverse the void often left by earlier unfulfilled needs for love or nurturing. However, if we can get you to feel better about yourself, reinforce your gains and offer support when needed, it goes a long way toward balancing the deficit.

However, psychiatric treatment cannot make you immune to anxiety. GAD is a chronic, lifelong condition that can wax and wane depending on your life stress. It is impossible to place a time limit on the appearance or disappearance of symptoms or when they will increase or decrease. The truth of the matter is that people who are anxious, even with good treatment, will not always be anxiety free. They can feel less anxious, feel anxious less often and be better able to cope with their nervousness when it does occur. But as I’ve said, anxiety is inherited: it is part of your DNA. Under certain circumstances and in certain situations, it may always pop up in your life. However, you can be less anxious more often and handle your anxiety better when it does arise. I will emphasize acceptance and proactive behavior rather than eradication, which is impossible.

There are many things that people can do to help themselves. Educating yourself about anxiety can be a first step in allowing perspective, reducing your feelings of apprehension and helplessness and allowing you to feel more hopeful and more in control of frightening feelings. This book is intended to help you understand stress and anxiety and to familiarize you with the symptoms of GAD and a broad range of possible treatment options. When you find yourself feeling apprehensive, tense and irritable, try the ten self-help techniques in this book that have proven beneficial to a wide variety of people suffering from anxiety. Hopefully, they will help you reduce your own anxiety, relax and enjoy life.