Anxiety Disorders
MICHAEL LINGEN
University of Göttingen, Göttingen, Germany
mlingen@gwdg.de
Synonyms
Panic disorder; Agoraphobia; Social phobia; Specific
phobia; Simple phobia; General anxiety disorder
(GAD); Obsessive-compulsive disorder (OCD); Acute
and post-traumatic stress disorder (PTSD); Hypochondria;
Health anxiety; Health phobia
Definition
Fear and anxiety are not primarily pathological, but
ubiquitous phenomena necessary for life and survival.
It is only in its extreme form that anxiety becomes
problematic. Anxiety is a feeling of apprehension
and fear characterized by physical symptoms such as
palpitations, sweating, and feelings of stress. Anxiety
disorders are a cover term for a variety of mental
disorders in which severe anxiety is a salient symptom.
Unlike the relatively mild, brief anxiety caused
by a stressful event such as an exam or a business presentation,
anxiety disorders are chronic, or can become
chronic, or grow progressively worse if not treated, and
are pathologically associated with other mental disorders.
Basic Characteristics
Epidemiology
Anxiety disorders rank among the most frequent psychological
diseases. 1–2% of the total population are
affected by an anxiety disorder in need of treatment.
Epidemiological studies concluded that the lifetime
prevalence of anxiety disorders is 14% (Regier 1998).
The 12-month prevalence of anxiety disorders is 12.0%,
specific phobias are most frequent (7.8%), followed
by panic disorders (12-month prevalence: 2.3%;
Wittchen and Jacobi 2005). The lifetime prevalence of
panic disorders is estimated to be 3–5 percent (Faravelli
et al. 2005). General anxiety disorder (GAD)
shows a lifetime prevalence of 5% in adults (Ballenger
et al. 2001). Prevalence rates of GAD are highest in
middle-aged women (> 45 years).
Aetiology
In a general model, anxieties can be explained as a consequence
of a dysfunctional interpretation of events,
which go hand in hand with a behavior that more
and more strengthens the dysfunction (e. g. avoidance).
According to this model, the ill-making interpretations
are the result of individual, relatively stable convictions
and doctrines. These are triggered by specific situations,
physical reactions or thoughts that influence the
(consequently very selective) processing and interpretation
of information. Most patients, for example, over
estimate dangers and underestimate their own capacity
to deal with them. As soon as a perceived danger
is assessed, a number of negative, automatic thoughts
build up (e. g. self-doubt, sceptic predictions). This process
of building up can be described as a vicious circle:
signs of an assumed dysfunction enhance the perception
of violability and influence the situational cognitions
and the dysfunctional attempts to cope with it;
these consist mainly in avoidance and safety-seeking
behavior. Consequently, the person is convinced that
only this behavior will avert the dreaded catastrophe.
Experiencing that the catastrophe did not occur or perceiving
that the situation could only be managed with
this behavior, suppresses the development of functional
assessments and behaviors. The term “safety-seeking
behaviors” (Salkowskisk 1991) refers to every behavior
used to avoid the dreaded event (e. g. diction or voice
modulation of socially insecure people, always carrying
a mobile phone or medication by people with panic disorders).
Cognitive-behavioral therapy therefore stresses
the need to modify this safety-seeking behavior;
the behavioral-therapeutic approach also distinguishes
between risk-factors (genetic precondition, life story),
triggering or releasing factors (stages or events of life
that were particularly stressful) and maintaining conditions
(e. g. self-energizing processes based on self-evaluation
and assessment of events as catastrophic, leading
to avoidance).
From a psycho-dynamic point of view, in contrast,
the symptoms of anxiety are seen as a result of inner
conflicts or of deficits of the so-called self-structure,
depending on the underlying concept. According to the
conflict model, the psychological defense of unacceptable
emotions (e. g. aggressive or egoistic impulses)
leads to a massive inner conflict which in turn “is frightening”
in the original sense. According to this model,
people would rather suffer from anxiety than have
a conflict with their consciences, an external authority
or other images of themselves; they, however, are not
aware of this inner conflict. The deficit model, on the
other hand, assumes that the anxiety cannot be fought
efficiently because of a weak ego, which then leads to
increasingly strong appearances of anxiety in the form
of symptoms. The continuous failure of psychological
defenses in the face of increasingly trivial stimuli therefore
leads to frequent and massive bouts of anxiety.
Consequences
In most anxiety disorders spontaneous remission is very
rare. On the contrary, these disorders tend to become
chronic at an early stage and sufferers have a high probability
of developing a second anxiety disorder (up to
50%) or a depression (up to 50%). A common combination
is anxiety disorder and substance abuse (up to
40%); this, however, in most cases, has to be regarded
as an unsuccessful attempt by sufferers to treat their
anxiety themselves. It is quite common that an anxiety
disorder finds its expression in somatic symptoms
(e. g. stomach ache) which are mistaken for symptoms
of a physical disease and consequently wrongly
treated. This in turn can lead to feelings of insecurity
in the patient and in extreme cases result in a kind
of vicious circle of increasing anxiety and increasing
somatic symptoms.
Treatment
Until a few years ago, anxiety disorders had been
regarded as difficult to treat. In recent years, however,
newer and more effective therapeutic strategies have
been developed. For all forms of anxiety disorders, psychotherapy
is the method of choice. The benefit or lack
of an additional treatment with medication is still under
debate. The benefit of a pharmaco-therapy as an interim
solution before the onset of psychotherapeutic measures
is undisputed. A permanent therapy with medication
(e. g. antidepressants, benzodiazepines), however,
is not always appropriate, as it prevents the establishment
of functional interpretations and coping strategies
and is also probably not quite harmless because of
potential addictions (as in the case of benzodiazepines).
The general objective of psychotherapy for anxiety disorders
is an adequate reduction of symptoms, a general psychological and physical improvement and, at the
same time, an increase in the quality of life.
Behavioral-therapeutic measures for the treatment of
anxiety disorders are based on the realization that anxieties
aremainly influenced by learning processes,maintaining
conditions (e. g. morbid gain in the form of
social care) and distorted interpretations. Consequently,
the specific therapeutic approach focuses on changing
these conditions, e. g. confrontation with anxietyeliciting
stimulus, relaxation techniques, etc.
A decisive focus in which the psychoanalytical therapy
differs from cognitive-behavioral approaches is the
psychoanalytical handling of the therapeutic relationship
with its specific interactions that are governed by
the patient’s unconscious conflicts. The objective is
that these unconscious conflicts, which are inextricably
linked to previous relationships, can be experienced and
dealt with in the present relationship with the analyst.
Cross-References
Acute and Post-Traumatic Stress Disorder (PTSD)
Agoraphobia
Dissociation
General Anxiety Disorder (GAD)
Hypochondria
Obsessive-Compulsive Disorder (OCD)
Panic Disorder
Social Phobia
Specific Phobia
References
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Lydiart RD,
Mayer EA, International Consensus Group on Depression
and Anxiety (2001) Consensus statement on depression, anxiety,
and functional gastrointestinal disorders. J Clin Psychiatr
62:53–58
Barlow DH (2002) Anxiety and its disorders: The nature and
treatment of anxiety and panic, 2nd edn. Guilford, New York
Brunello N, Davidson JR, Deahl M, Kessler RC, Mendlewicz J,
Racagni G, Shalev AY, Zohar J (2001) Posttraumatic stress
disorder: Diagnosis and epidemiology, comorbidity and
social consequences, biology and treatment. Neuropsychobiology
43:150–162
Davey GCL (ed) (1997) Phobias: A handbook of theory, research
and treatment. Wiley, Chichester
Goodman WK, Rudorfer M, Maser JD (2000) Obsessive-compulsive
disorder. Contemporary issues in treatment. Erlbaum,
Mahwah
Goodwin RD, Faravelli C, Rosi C, Cosci F, Truglia E, De
Graaf R, Wittchen HU (2005) The epidemiology of panic
disorder and agoraphobia in Europe. Eur Neuropsychopharmacol
15:435–43
Wittchen HU, Jacobi F (2005) Size and burden of mental disorders
in Europe: A critical review and appraisal for studies.
Eur Neuropsychopharmacol 15:357–76
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