Anxiety disorders are the most common, frequently occurring, so-called mental disorders in the United States (we say “so-called” because there are compelling reasons to doubt the notion that these conditions have their etiology in the “mind” of individuals). Differing from everyday stress and anxiousness caused by stimuli such as examinations, new jobs, and morning traffic, anxiety disorders are pervasive and chronic and may need professional care to alleviate or cure them. Over 19 million Americans between the ages of 18 and 54 are estimated to meet the formal diagnostic criteria for one or more anxiety disorders (National Institute of Mental Health [NIMH], 1999). Anxiety disorders
can be the result of life stressors and events, learning, parental upbringing, illness-induced stress, genetic endowment and other biological conditions, and the inability to cope with and manage all of those factors at once. Mental health problems such as anxiety present particular problems during adulthood, including contributing to high rates of suicide, relationship problems, and difficulty
functioning in society. Some specific events during adulthood (having children, divorcing, and expectations about success) can contribute to the development of an anxiety disorder.
Some anxiety is helpful, keeping persons alert and aware of their environment; too much anxiety, however, fatigues a person and can lead to diminished functioning. Anxiety disorders are linked by extreme or pathological anxiousness as the principal disturbance. The term anxiety disorder is formally given to pathological disturbances of affect, thinking, behavior, and physiological activity (U.S. Surgeon General, 1999). This subsumes emotional responses such as
intense fear and feelings of dread and physical symptoms of shortness of breath,
cold hands and feet, perspiration, lightheadedness or dizziness, rapid heart rate,14
Preventive Interventions for Adult Emotional and Mental Problems trembling, restlessness, and muscle tension (U.S. Surgeon General, 1999). Anxiety disorders are characterized by an excessive or inappropriate state of fear, apprehension, and uncertainty (NIMH, 1999).
TYPES OF ANXIETY DISORDERS
There are several specific types of anxiety disorders, including the following. Phobias
The underlying element in all phobias is an irrational fear of something. They
can range in intensity from mild to traumatic, but “in all cases there is a sense of
predictability which accompanies them” (Clark & Wardman, 1985, p. 13). The
following are general definitions of several common phobias.
Specific Phobia
Formerly known as “simple phobia,” specific phobia is persistent fear of an object or situation. According to the Diagnostic and Statistical Manual of Mental
Disorders text revision (DSM; American Psychological Association, 2000), there
are five subtypes of specific phobia: animal type (generally with childhood
onset; examples include fear of snakes, dogs, or insects), natural environment
type (fear of storms, heights, weather), blood-injection injury type (fear cued by
seeing blood), situational type (fear cued by a situation such as crossing a
bridge, driving, being in enclosed places), and other (e.g., fear of clowns, claustrophobia, fear of choking). Exposure to the stimulus causes intense fear and
stimulates avoidance behavior by the individual. The fears are excessive and unreasonable. Most specific phobias begin during childhood and eventually disap-
pear. They are more common in women than in men.
Social Phobia
Also called “social anxiety disorder,” social phobia is diagnosed when a person’s
shyness and social avoidance becomes so severe and intense that it causes impairment or dysfunction. The anxiety-evoking stimulus involves being observed,judged, or evaluated by others. Social phobia is one of the most common anxiety
disorders and can become worse over time if not treated (Thyer, 2002; Thyer,
Tomlin, Curtis, Cameron, & Nesse, 1985). Social phobia is defined by the DSM
as “marked or persistent fear of social or performance situations in which embarrassment may occur” (American Psychiatric Association, 2000, p. 450). Situations that are often feared by people with social phobia are speaking in public,
participating in sports, being in public places, meeting new people, talking to an
authority figure, using public lavatories when others are present, and musical or
other performances. Clinical presentations may be different across cultures. By
some criteria, social phobia is the third most prevalent mental health care problem in the world.
Agoraphobia
The word agoraphobia literally translates as “fear of the marketplace” (Clark & Wardman, 1985, p. 8) and refers to a generalized fear of being in public places.
More specifically, agoraphobia is “anxiety about being in places or situations
from which escape might be difficult (or embarrassing) or in which help may not
be available in the event of having a panic attack or panic-like symptoms”
(American Psychiatric Association, 2000, p. 432). This anxiety usually leads to
the individual avoiding situations in which the anxiety may arise. In severe
cases, individuals are unable to leave their comfort zone and often self-isolate to
the point of being housebound.
General Anxiety Disorder
This disorder is characterized by excessive anxiety or worry accompanied by at
least three of the following: restlessness, fatigue, lack of concentration, muscle
tension, irritability, and lack of sleep. General Anxiety Disorder can manifest in
physical symptoms such as trembling, twitching, muscle aches, and soreness as
well as diarrhea and vomiting. The intensity and worry individuals report is
grossly out of proportion to the real risk. This disorder frequently occurs with
mood disorders and other anxiety disorders and is more common in women than
in men.
Panic Disorder
Panic Disorder is characterized by panic attacks, which are described as a “rush
of fear or discomfort that reaches a peak in less than 10 minutes” (Antony &
Swinson, 2000, p. 12). These attacks are accompanied by physical symptoms such
as a racing heart, shortness of breath, sweating, shaking, chest pain, faintness, and
hot flashes or chills. Panic attacks often occur in the absence of any specific stimuli but can be brought on by stressful events such as an exam or a public speaking
event. According to the DSM (American Psychiatric Association, 2000), there are
three subtypes of Panic Disorder: unexpected (occur without warning or a precipitating event), situationally bound (occur in a particular situation, e.g., with phobia exposure), and situationally predisposed (these fall somewhere in between the16
Preventive Interventions for Adult Emotional and Mental Problems
two previous). Panic attacks are often disabling. Panic Disorder is estimated to
impact more than 4% of Americans (Datilio, 2001).
Obsessive Compulsive Disorder
The DSM defines Obsessive Compulsive Disorder (OCD) as “recurrent obsessions or compulsions that are severe enough to be time consuming (more than 1
hour a day) or cause marked distress or significant impairment” (American Psyhiatric Association, 2000, p. 458). OCD usually presents with both obsessive
thoughts and compulsive behaviors, although individuals may suffer from only
one. The obsessions are characterized by persistent thoughts, images, or impulses
that cause marked anxiety or stress; for example, the thought of germs contaminating one’s hands, ruminating over whether one locked the door, or the urge to
blurt out an obscenity. The compulsive behaviors are often associated with the
obsessions: with the thought of germs comes excessive hand washing, even to the
point where the skin is extremely chafed. Adults with OCD usually realize that
these actions are inappropriate, unreasonable, and excessive. If they do not come
to this realization, the illness is referred to as OCD with poor insight.
Posttraumatic Stress Disorder
In Posttraumatic Stress Disorder (PTSD), a person who has experienced a traumatic situation that involved actual or threatened death or serious bodily harm
responds with trauma-related symptoms of intense fear, helplessness, or horror.
Events can include, but are not limited to, crime victimization, wartime events,
or serious accident. Symptoms can include distressing dreams about the event,
feeling as if the event is recurring, stress surrounding the anniversary of the
event, flashbacks, or avoiding activities associated with the event. In addition,
the individual may have difficulty concentrating, may have insomnia, may dis-
play outbursts of anger, may be unable to recall the traumatic event, and may
display a lack of interest in activities. PTSD is common among victims of rape
and personal assault and those who serve in active combat. Sometimes the victim is unable to make the connection between the traumatic event and current struggles.
PREVENTION
There has been much research on the diagnosis and treatment of adult anxiety
disorders but little attention paid to prevention. Anxiety disorders can be prevented provided the person has access to treatment or prevention information in
the early stages of the disorder (Leighton, 1987). Delay in treatment and a lack
of information about anxiety disorders and management contribute to the development of a diagnosable anxiety disorder.
The primary problem with attempting to prevent anxiety disorders is that individuals often try to camouflage their disorder instead of getting treatment.
They may hide their symptoms from friends, family members, and coworkers,
leading to a delay in professional treatment and intervention for perhaps many
years, or until they are so uncomfortable and the symptoms so overwhelming
that they are functionally impaired (Craske & Zucker, 2001).
Anxiety prevention programs have slowly grown in numbers, but few have
been empirically supported. Three types of prevention programs are discussed
in this chapter: universal, selective, and targeted. Programs aimed toward preventing the entire population or a community from feeling stressed or anxious
about life events are monumental undertakings. This type of program is called a
universal preventive intervention. Selective interventions are aimed at a population known to be at risk for anxiety problems or at higher risk than the average
person, such as adults who have been exposed to violence at home or in the community. Preventive interventions aimed at adults who are already showing signs
and symptoms of anxiety disorders are called targeted.
TRENDS AND INCIDENCE
The cost of anxiety disorders to the United States is more than $42 billion a year,
with more than $22 billion attributed to repeat medical care costs in a search for
relief from symptoms that look like physical illness (Greenberg, Sisitsky, &
Kessler, 1999). People with anxiety disorders are three to five times more likely
to go to the doctor and six times more likely to be hospitalized for psychiatric
disorders. About one in seven adults in the United States and Britain are affected
by anxiety disorders each year (Brown, 2003; see Table 2.1 on page 18).
RISK FACTORS
The predictors and risk factors for anxiety disorders have been well studied. A
combination of biological, psychological-behavioral, and social-environmental
factors determines if an individual will develop an anxiety disorder (Substance
Abuse and Mental Health Services Administration [SAMHSA], 2003). The
Anxiety Disorders Association of America suggests that anxiety disorders develop from a complex combination of risk factors, including genetics, brain
chemistry, personality, and life events
Preventive Interventions for Adult Emotional and Mental Problems
Life stressors and events may include severe or life-threatening trauma
either during adulthood or childhood that contributes to the stress level of an
individual (see Thyer, 1993). Stressors may include maltreatment during child-
hood, exposure to violence in or external to the home, violent relationships duing adulthood, and being exposed to violence or trauma in personal or work environments. Some events can result in distress and dysfunction that, if not treated or managed, manifests as a mental illness, such as an anxiety disorder (U.S. Surgeon General, 1999).
For a substantial proportion of individuals who meet the criteria for an anxiety disorder, a clear biological or psychosocial etiology cannot be established.
Women are at twice the risk for anxiety disorders compared to men, with the exception of OCD and possibly social anxiety. Possible explanations for this discrepancy include hormonal differences, cultural pressures, and a higher rate of reporting anxiety. Anxiety disorders appear to have a genetic factor and run in families. Many other factors influence an individual, including social, home, and peer relationships, but genetics plays a strong role.
EFFECTIVE UNIVERSAL PREVENTIVE INTERVENTIONS
The following interventions group all anxiety disorders together and attempt to
prevent them for the entire population or community.
National Institute of Mental Health Anxiety Disorders
Education Program
This program was developed by the NIMH Communications and Public Liaison
Office. The purpose of the program was to educate and increase awareness
among the public and health care providers about anxiety disorders and their
“realness,” and to convey the message that these conditions can be effectively
diagnosed and treated. The primary goal of the program was to improve the lives
of people with anxiety disorders. A six-pronged approach was used to disseminate information:
• A toll-free information line (800-ANXIETY) to receive free printed materials.
• A web site about anxiety disorders (www.nimh.nih.gov/anxiety).
• Radio and television public service announcements.
• Printed and audiovisual materials discussing diagnosis, treatment, and referral information about anxiety disorders.
• Print media outreach.
• Partnerships with community mental health, health, and civic organizations
that provide public and professional education and research at the local
level.
National Anxiety Disorders Screening Day: May 1
The purpose of this day is to destigmatize anxiety disorders, educate the public,
and help people with anxiety disorders connect with service providers to obtain
treatment. This has been a federal education and prevention program since 1994.
National Campaign on Anxiety and Depression
Awareness 2004
This program is a year-long campaign to educate the public about the signs and
symptoms of anxiety and depressive illnesses and guide affected individuals to
treatment networks. The campaign includes public service announcements, print
media releases, promotion of films about mental health issues, visits to communities, colleges, and universities, and a web site and toll-free number. Individuals found to have signs and symptoms of anxiety and depressive illness will be referred to a registered mental health provider to receive a free telephone or in person mental health screening.
