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July 2, 2020

Anxiety: A Primer

About the Author
Deborah Kostianovsky

See the exhibition here


A glimpse of Rory’s internal dialogue: “Did I wash my hands for a full twenty seconds? Maybe I should do it again. And just to play it safe, maybe I’ll take a shower since I just went outside. And in the shower I’ll wash them again just to make sure I’m safe. My hands are cracked and dry from washing, but I can’t help repeatedly washing, even though I know they’re clean. Did I accidentally touch my face after touching the park bench yesterday? I think I did. Well my eye was itching, and I impulsively scratched it. Now I can’t sleep or concentrate on my work because I’m afraid I was exposed to the Coronavirus. That makes three sleepless nights in a row, and countless others before that. Last week I couldn’t sleep because I went for a walk and someone coughed nearby. I think she was about thirty feet away. Or maybe it was ten feet. Maybe it was only two feet. I’m bad at judging distances. But I think the wind was blowing in my direction.” And here’s Jill’s thoughts: “My six-year old kid spontaneously ran into the park and hugged his friend, then they both wrestled on the ground for a few minutes like puppies. I’d say it was incredibly cute if I wasn’t so scared that he didn’t remain socially distant from his friend. Should I admonish him for running ahead of me toward his friend and not maintaining social distance? He’s only six, for God’s sake, and doesn’t understand. I worry about making him anxious, and I don’t want him to pick up on my anxiety.” And meet John: “I’ve had treatment for panic disorder and agoraphobia in the past. I was doing better but I’ve been having lots of trouble leaving my house since this pandemic began. Often the moment I try to set foot out the front door, I begin to hyperventilate, my heart starts racing, I feel dizzy, and I feel like I have to go back inside and lie down. Sometimes I feel like I’m going crazy, or even that I might die. Sometimes this happens to me when I’m cooking the dinner or making the bed, as if to remind me of the problem even when I’m inside. It makes me feel scared to go out in public. What if I faint or fall down in a panic outside? Will anyone help me? It’s not worth going outside.” Larry: “The state of the world is making my anxiety so much worse.” And here’s Terrence: “I’ve got this undercurrent feeling of worry and dread that I’ve never had. I’m doing everything I should be doing to avoid the virus, but I’m still scared. I’m afraid to go back to work, and don’t know if I can even when we are told to do so.” Each of these hypothetical scenarios of imagined persons captures facets of expected, adaptive worry as well as problematic anxiety that likely lurks, almost like an invisible separate pandemic, in many of our minds. As a practicing psychiatrist for thirty years (now following my passion to write about art), I have seen many similar scenarios.
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Of course, short-term anxiety, fear, and worry are an expected response to stress, and these are unquestionably stressful times. Many of us have felt anxiety or fear of some type, perhaps similar to one of the scenarios above or in a different form, at some point during this pandemic. Fear is a response to an immediate real or perceived threat, and in the short term it leads to hormonal and physiological changes (such as increased heart rate and respiratory rate, which together help move blood, oxygen and nutrients to muscles, the heart, and other vital organs, among many other acute ways the body ramps up to confront impending danger); these physiological changes support the body in a fight-flight reaction. In contrast, anxiety is anticipation of a future threat, and as such is often associated with muscle tension, vigilance and avoidant behaviors in preparation for a future danger.[1] Of course both can exist together or separately depending on the person and the circumstances. Panic attacks are a particular type of fear response. Fear and anxiety are adaptive, evolutionarily developed responses to threats which aid in dealing with an imminent or future stressor. The symptoms of both can be uncomfortable but potentially serve as a bodily alarm, leading to bodily changes that can spurn appropriate, life-saving actions. So where on the continuum do anxiety and fear cease being adaptive and expected, and become dysfunctional? How do doctors know when the symptoms of ongoing anxiety reach the threshold for clinical anxiety? Along similar lines, is anxiety an overarching general diagnosis or are there different kinds of anxiety?
Any discussion of anxiety should first point out some jaw dropping statistics. Anxiety disorders as a group are the most common mental illness in the US. Anxiety affects 40 million adults older than age 18 and affects 18.1% of the population. A disturbing corollary is that despite the fact that anxiety disorders are very treatable, only 36.9% of people suffering with anxiety receive treatment. [2] And that’s all during normal times. Incredibly, Census Bureau statistics reveal that roughly one third of Americans have displayed clinical signs of anxiety and/or depression since the pandemic began. These numbers are based on a short series of questions and do not imply that these people have all been diagnosed with depression and anxiety, but it does point to clearly elevated levels of anxiety over the last few months. [3] No big surprise there. Yet those are big numbers. Clearly this is not a small problem, or one that should be ignored. So now that we have a better idea of the magnitude of the problem, let’s discuss how a diagnosis is made. In general, anxiety and fear become problematic when the symptoms are severe, last for a long time (more than six months for a clinical diagnosis of most anxiety disorders) and interfere with daily functioning. There are many types of anxiety disorders, each specified in the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The clinically relevant anxiety disorders differ from each other in the circumstances that might induce the fear, anxiety, or avoidance, and the associated cognitive counterparts. The clinical diagnosis of an anxiety disorder presupposes that the symptoms are not attributable to a medical condition or the effects of a substance or medication.[4] There are a whole host of anxiety disorders such as social anxiety, separation anxiety, selective mutism, and specific phobia, but these will not be covered. Also, Post-traumatic stress disorder or acute stress disorder are other anxiety-related syndromes that are beyond the scope of this article. There are three anxiety-related disorders that seem most likely to manifest de novo or to be exacerbated by the pandemic. These include generalized anxiety disorder, panic disorder, and obsessive compulsive disorder. Obsessive compulsive disorder is not officially classified as an anxiety disorder in DSM-5 but does have many features in common with anxiety so it will be included here. Let’s look at the criteria for each disorder, as delineated in DSM-5.
Nothing, Eli Smith
Generalized Anxiety Disorder (GAD), a common form of anxiety, has very specific diagnostic criteria, as do all of the Anxiety Disorders. The main feature includes excessive worry and anxiety about a number of events or activities, such as work, school, or performance. As noted in DSM-5, the intensity, duration, and frequency of the anxiety is out of proportion to the actual likelihood or impact of anticipated event. Excessive anxiety and worry occur most days for at least six months. So technically, a new onset generalized anxiety disorder could not be diagnosed in relation to the start of the pandemic, as the world has only been unhinged for the past three months. Unless, of course, symptoms were occurring prior to the pandemic and the pandemic merely exacerbated them. Even if the symptoms are under the time criteria for six months required for a clinical diagnosis, a course of treatment may certainly be warranted depending on how debilitating the symptoms are. The anxiety and worry also need to be associated with three or more of the following symptoms: restlessness/feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance. These symptoms need to cause significant distress or impairment in social, occupational, or other important areas of function. There are a few features that distinguish generalized anxiety disorder from a non-pathologic process: In GAD the worries are excessive to the situation and interfere with functioning. Also, the worries associated with GAD are more pervasive and distressing than that seen in everyday worries and often occur without clear precipitants. Lastly, the worries are more likely to be associated with physical symptoms in GAD than in everyday worries (for example, feelings of restlessness, insomnia, being on edge). GAD interferes with someone’s capacity to do things quickly and efficiently, and the associated symptoms contribute to the impairment. [5]
Yet To Find a Name, Eli Smith
Though closely related to Anxiety Disorders, Obsessive Compulsive Disorder (OCD) is no longer classified as an anxiety disorder in DSM-5 but it is being included here as it has features related to anxiety. Other related disorders include body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling), excoriation (skin picking). The main characteristics of OCD include obsessions and compulsions. Obsessions are recurrent thoughts, urges, images that are experienced as intrusive or unwanted. Compulsions are rigid, repetitive behaviors or mental acts that a person feels must be performed in response to an obsession. In order to make a diagnosis of OCD there must be recurrent obsessions, defined as noted above but there must also be an attempt to ignore or suppress these thoughts with some other thought or action (performing a compulsion). Compulsions are repetitive behaviors (such as hand washing, checking, counting, cleaning, etc) that the individual feels driven to perform as a result of an obsession. The behaviors are aimed at preventing or reducing anxiety. These behaviors and thoughts must be time consuming (more than one hour daily) or cause significant distress in important areas of functioning in order for a diagnosis of OCD to be made.[6]
Lastly, panic disorder is diagnosed by a constellation of symptoms including unexpected panic attacks. A panic attack is a sudden surge of fear or discomfort that reaches a peak within minutes and during which specific physical and cognitive symptoms occur. Four or more of the following symptoms usually occur during a panic attack: palpitations, sweating, trembling, feelings of shortness of breath, feeling of choking, chest pain, nausea, feeling dizzy, lightheaded, faint, chills or heat sensations, numbness or tingling (paresthesias), feelings of unreality (derealization) or feeling as if detached from oneself (depersonalization), fear of losing control or “going crazy,”  fear of dying. At least one of the attacks is followed by one month or more of one of both of the following: worry about additional attacks, maladaptive behavioral change related to the attacks, (such as refusal to go to the store, etc.) The presence of an expected panic attack does not rule out the diagnosis of panic disorder as the attacks may be both unexpected and expected. [7] A linked disorder, sometimes associated with a panic attack, is agoraphobia. Agoraphobia includes significant fear about two out of five of the following: using public transportation, being in open spaces, being in enclosed spaces, being in a crowd, being outside of the home alone. In this case, these situations are feared or avoided because of thoughts that escape might be problematic or help not available in the event of developing panic-like symptoms. The particular situation always provokes anxiety and as a result the person develops avoidance of it. The fear is usually out of proportion to the actual danger. In order to make a diagnosis, the symptoms typically lasts six months or more, and the fear, anxiety or avoidance causes distress or impairment in functioning. [8]
TurbulentS, Eli Smith
Between the pandemic, fear of a changed future, social distancing leading to loneliness and isolation, worry about elderly parents and those in our midst who are at high risk from the virus, unemployment, racial injustice, political ineffectiveness and incompetence, there are a myriad of issues in our present world that could potentially lead to fear and anxiety. Some of us are able to throw ourselves into our work, our passions, or our relationships and remain unscathed by the disasters around us. But some of us may experience a range from mild anxious stirrings, a few anxiety symptoms, or full-blown anxiety disorders. Perhaps you have experienced some of the symptoms in one of the vignettes above, or perhaps you are noticing one or two GAD symptoms. If you are noticing that stress or anxiety interferes with your daily activities for more than a few days in a row, contact your health provider. Anxiety is very treatable. And it’s always a good idea to talk with someone and get help. Just talking with an objective professional can often make a difference, and most therapists will provide telehealth services.  The most common treatments for anxiety disorders are cognitive behavioral therapy and SSRI’s (selective serotonin reuptake inhibitors, a type of antidepressant). In addition to professional treatment, there are several things you can do at home to help calm your anxiety. Limit the news to short bursts twice daily rather than continually watching TV or repeatedly checking the news on social media. Other self-treatments include daily exercise, eating healthfully, meditation, getting plenty of sleep, connecting with friends and family, and avoiding alcohol and drugs. [9] Don’t hesitate to get help if you need it. This is an unprecedentedly stressful era in history, and there is no shame in feeling stressed.
This content (or any internet-based content) should not be used as a substitute for direct medical advice from your doctor or clinician.
CDC Mental Health Resources
American Psychiatric Association – What Are Anxiety Disorders?
ADAA – Coronavirus Anxiety Helpful Tips and Resources – Get Immediate Help
[1] Diagnostic and Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association Publishing, 2013, p. 189.
[2] Anxiety and Depression Association of America
[3] Centers for Disease Control and Prevention, National Center for Health Statistics
[4] Diagnostic and Statistical Manual, Ibid.,p. 189.
[5] Ibid, p. 222.
[6] Ibid., p. 237.
[7] Ibid., p. 208.
[8] Ibid., p. 217.
[9] World Health Organization, #Healthy at Home
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