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A Brief Look At Anxiety Disorders

‘The persistent nature of anxiety disorder over time, with its childhood antecedents and often recurrent prognosis, means that it may dominate sufferers’ lives. Only chronic heart disease produces more disability’: Dr. Ben Green, Consultant in Psychological Medicine, Halton Hospital. Dr. Green also estimates that, based on the findings of Croft-Jeffreys & Wilkinson in 1989, the current cost to the UK of neurotic illness must exceed half a billion pounds a year.

Anxiety disorders are the most common mental health problem that occur in children and adolescents. According to one large-scale study of 9 to 17 year olds, entitled Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA), as many as 13% of young people had an anxiety disorder in a year.
(National Institiute of Mental Health)

Mixed anxiety/depression, generalized anxiety, depressive episodes, all phobias, OCD and panic disorder have a weekly prevalence of 16% for all adults aged 16-64.
(WHO Guide to Mental Health; source OPCS Survey of Psychiatric Morbidity Report 1. London; HMSO, 1995)

‘Recent research has suggested that almost a quarter of the population will experience an anxiety disorder during their lifetime. The negative impact of abnormal anxiety on a person’s ability to work and socialize is significant’.
(Health Press Ltd. Oxford, 2000)

Professor Marks says in ‘Fears, Phobias and Rituals’ (1987):
‘Clinicians began to see that what clients did themselves between therapy sessions could be as important or more important than the actual sessions in the clinic. It turns out that most sufferers can complete live self-exposure successfully without a therapist having to be present’ ‘Mixed anxiety-depression is the most common presenting problem in primary care, accounting for a sixth to a third of all attenders. Health care services would be swamped if all sufferers asked for help.’
Add this to the words of Wittchen & Essau in ‘Panic Disorder and Agoraphobia, A Comprehensive Guide for the Practitioner’ (1991): ‘... only a fraction of persons affected by anxiety disorders are actually seen and treated in mental health settings. These treated samples are generally not representative of the entire population with anxiety disorders because clinical services have specific selection processes for patients.’ Besides confirming the efficacy of self-help, these statements underline the fact that a great many people in need receive no help at all.
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Social Anxiety Disorder (SA)

This disorder will involve excessive shyness and unease around strangers and peers that becomes so extreme that it interferes with normal social development and leads to isolation and depression. Sufferers will persistently avoid situations where they may be scrutinised or criticised by others (or will stay in the situation with dread) and will feel compelled to do this even though their anxiety may be exacerbated by the knowledge that this is an excessive reaction. They will avoid or dread situations like public speaking, eating or writing in public and may overly fear blushing or vomiting or otherwise embarrassing or humiliating themselves in front of people, perhaps leading to a total avoidance of social situations. A vicious circle can build up (DSM-IV 1994) of anticipation leading to fearful cognitions of anxiety symptoms in the feared situation leading to real or perceived poor performance, leading in turn to embarrassment and increased anticipating anxiety - and so on. DSM-IV states that ‘common associated features of Social Phobia include hypersensitivity to criticism, negative evaluation or rejection; difficulty being assertive; and low self-esteem or feelings of inferiority’ (p.424). As opposed to Agoraphobics, Social Phobics don’t tend to seek out a trusted companion to assist them and they don’t seem to have Panic Attacks while alone. Onset is usually between the ages of 15 and 20.
(various studies - Marks, 1987; Edelmann, 1992). ‘Social anxiety as trepidation and concern about social encounters is a very common and distressing condition reported by as many as 40% of the general population’ (Edelmann 1992 p.74)

Prevalence rates for Social Anxiety Disorder ...are estimated to be up to 4% with boys and girls equally likely to develop it. Since children with SA are usually quiet in school and do not exhibit behavioural problems, teachers often do not recognize the disorder. What can complicate matters is that anxiety disorders often run in families and children with SA may have a parent suffering from the same disorder. The parent may attempt to shield the child from social situations, and that may confirm the child’s fears about social interaction. Also there are co-morbid conditions associated with SA, such as other anxiety disorders and major depression. The course of the disorder is chronic. In adolescence, these children are at risk for substance dependence. Furthermore, there is continuity between adolescent and adulthood SA.
(Karen Dineen Wagner, M.D. Ph.D)
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Generalised Anxiety Disorder (GAD)

Excessive and often unrealistic worry is the chief characteristic of GAD. Children with this problem may be perfectionists, restless, find it difficult to concentrate, have trouble sleeping and may refuse to go to school.

GAD is ‘characterised by chronic worry about a multitude of life circumstances’ (Barlow et al, 1986a). By definition as a disorder, GAD must involve unrealistic or excessive worry about two or more life circumstances for six months or more and there should be more worry days than worry-free days (DSM-III-R 1987 in Edelmann, 1992, p.139). Focusing on family and finance seems to be most common. This worry could concern strong feelings of threat, perhaps misconceptions of situations coupled with a highly sensitive internal readiness to acquire threatening information; to ascribe the most threatening scenarios to such information and to believe that such situations are uncontrollable. This could be aggravated by an understandable tendency to be preoccupied with the self, which may intensify the emotional experience. (Mathews and MacLeod 1987; Barlow, 1991; Rapee, 1991, various studies p.79 & p.83).

Current classifications suggest that this is the most common anxiety disorder with a slow gradual onset with males slightly outnumbering females (various studies Edelmann 1992, p.143). However, concerning onset, there is research (various studies, Rapee 1991 p.78) that suggests it can be as far back as a person can remember; and that GAD patients typically present with a lifetime history of anxiety, apprehension and physical symptoms (various studies Sanderson & Wetzler 1991 p.131)

GAD co-occurs with other disorders, particularly simple phobia and social phobia. Sanderson & Wetzler further suggest that ‘patients with depressive disorders are more likely to have GAD as well than are patients with anxiety disorders’ and that the majority of GAD sufferers have other disorders as well (1991 p.123). In contrast to those with Panic Disorder who may worry about panicking, GAD sufferers are likely to realise that their symptoms (DSM-III-R) such as trembling, upset stomach, sweating, dry mouth flushes or chills, are due to their own anxiety and hence harmless (Edelmann 1992, p144). However, in a discussion of many research studies (1991, ps.87-8 & 288) Rapee says that the worry in GAD, as well as being uncontrollable, involves a predominance of thought (verbal) activity rather than images and is conscious, attention-demanding and difficult to switch off. This may allow generalised anxiety disorder sufferers to avoid thinking about the feared situation so leaving them unable to work through their problems. In this way they maintain the anxiety. Worry may also be reinforced as a ‘coping technique’ (albeit a destructive one) by the frequent non-occurance of feared outcomes (Edelmann, 1992 various studies p.145-148).
GAD sufferers may be ‘chronic worriers’ seeking treatment only as a last resort and relying mainly on self-help or GP prescribed medications (Barlow 1988; Edelmann 1992 p.157).

The prevalence rates for GAD in children is about 5% with no significant differences based upon gender mean age of onset is approximately 8 years of age Children and adolescents with GAD often have co-morbid disorders such as depressive disorders and other anxiety disorders which can worsen the course of the illness. GAD in youth tends to be chronic. Since childhood is a period of substantial emotional, social and cognitive growth, the chronicity of this disorder can have devastating effects on a child’s development.
(Karen Dineen Wagner, M.D. Ph.D)
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Panic Disorder

For a clinical diagnosis, this disorder involves periods of fear or discomfort and must include at least four of the following symptoms which appear during each panic attack: Dyspnoea (shortness of breath), palpitations or accelerated heart rate; chest pains or discomfort; choking or smothering sensations; dizziness; unsteady feelings or faintness; trembling or shaking; paraesthesias (tingling sensations); sweating and hot-and-cold flushes; fear of dying, going crazy or doing something uncontrollable; depersonalisation (feeling strange, unreal, disembodied, cut off or far away from immediate surroundings, voice strange and distant); or derealisation (similar changes to depersonalisation seem to occur in the environment, as if the world is vague, distant or hardly there). (Edelmann 1992, p76; Marks 1987 p342; DSM IV, 1994 p.405) Various studies in Edelmann (1992,r p78-79) suggest that over half the general population (including teens) have experienced at least one panic attack although for the majority the severity of symptoms was only moderate. This majority on the low side of the symptom continuum also report less dizziness, dyspnoea, fear of going crazy and fear of losing control. At disorder level, by definition, the problem is ‘characterised by recurrent, unexpected (spontaneous, uncued ‘out of the blue’) Panic Attacks’ (DSM-IV 1994 p.410). DSM-IV further notes that frequency and severity of Panic Attacks varies a good deal - for example, short bursts over a week with gaps of weeks or months in between, or once a week over a period of months. Also that Panics can be nocturnal - waking people from sleep. ‘Limited-symptom’ attacks within the disorder are possible (DSM-IV p.407). These are identical to ‘full’ panics but involve less than four of the symptoms described above.

Those with a clinical disorder might be expected to be more anxious about symptoms and more afraid of the results of the bodily sensations, so aggravating the problem. And a high percentage of anxiety disorder sufferers of all types would be expected to have panic attacks. Within other disorders however, panic would be in response to stimuli rather than spontaneous. These sufferers, anticipating panic might expect it to happen again in similar circumstances, misinterpreting bodily symptoms and their imagined catastrophic results so being more ready to feel out of control and on the brink of craziness or death. Fuelling fears, they may bring on a full-blown panic attack. Disorder sufferers may also become demoralised (DSM-IV 1994 p408) - ashamed or unhappy, if their normal routine becomes difficult. This can lead to broader problems. Major Depressive Disorder seems to affect over half those with Panic Disorder. With about a third of these the depression precedes the onset of Panic Disorder. In the remaining two-thirds depression occurs coincident with or following the onset of Panic Disorder (DMS-IV 1994 p408)

About 1% to 2% of all adults have multiple panic attacks. If you look at adults with Panic Disorder, 20% had their first panic attack before age 10 ...In females, stomach aches and headaches together are very, very common. In fact, recent studies have shown that when these two are found together in the same child, 69% had an anxiety disorder... Panic Disorder in children is a very disabling condition... While perhaps 10% of children will have a panic attack, about 1% to 2% will develop Panic Disorder. Of those that do develop Panic Disorder, 10% to 35% will recover... Of those who continue to have Panic Disorder as they go into adulthood, many will develop other psychiatric difficulties.
(Jim Chandler, MD)
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Obsessive/compulsive Disorder (OCD)

At disorder level, OCD means spending more than an hour a day being involved in obsessions and compulsions. Obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and inappropriate and cause marked anxiety and distress. These are not excessive worries about real-life problems. The sufferer attempts to suppress such thoughts, impulses or images, or to neutralize them with some other thoughts or compulsive actions. Compulsions are repetitive behaviour such as washing or checking; or thoughts such as praying, counting, or silently repeating words. These activities are not connected in a realistic way to the obsession. OCD can be hugely disabling and life-long.

Community surveys of adolescents have suggested that at any given time 1% to over 3% are experiencing symptoms of OCD. Children as young as 5 or 6 can show full-blown OCD. Between 30% and 50% of adults with OCD reported that their symptoms started during or before mid-adolescence. Problems at a pre-clinical level may affect ten times those who can be diagnosed with the actual disorder. This would involve obsessions and compulsions at a nagging but not disabling level.
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Separation Anxiety Disorder (SAD)

Agoraphobia and Panic often go together and are common in children who have Separation Anxiety Disorder. This disorder concerns worry about being away from home or about being far away from parents, that is much more than is normal for that child’s age. In adolescents this might include worry about loved ones being harmed in some way, fear that they will not return home, fear of sleeping alone and refusal to go to school. Stomach-ache, head-ache and constipation are the most common physical symptoms.
(Jim Chandler MD and ‘Lifeline’)

A child with SAD may experience repeated nightmares about separation; repeated occurrence of physical symptoms (beyond those mentioned above), such as nausea and vomiting, and excessive distress such as anxiety, crying, tantrums, misery, apathy or social withdrawal. It seems likely that SAD and GAD are related in children and adolescents depending on psychological development. That is ‘life worries’ will present at different levels and will be concerned with different sources according to a child’s physical and emotional age. A child with SAD alignment, as mentioned above, will probably worry about the attachment figure disappearing and be clingy and focus heavily on help-seeking; while the GAD aligned child will worry excessively about his or her adequacy in many areas and be constantly focused on personal shortcomings. Various studies have shown SAD and GAD as affecting around 6-7% of children with SAD predominating at age 11 and GAD at age 15.
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