Some people have called anxiety the Disease of the 21st Century; and on an anecdotal level, it's easy to understand how someone might think anxiety worthy of the title. We've all experienced it at one time or another -- that horrible feeling when the whole world seems to be crashing down on us. But is humanity truly in the grips of an anxiety epidemic? Top Image: hikrcn/Shutterstock.
On its own, anxiety is a normal part of life, a psychological throwback to an earlier evolutionary time when our ancestors had to be on constant alert, ready to call upon their fight or flight response.
But for some, anxiety strikes at the most unexpected of times. It makes us imagine that things in our life, or what's happening right now, are far worse than they really are -- and the effects can be quite debilitating. Anxiety can result in fear, uncertainty, circular and racing thoughts and the avoidance of certain behaviours. It can affect our ability to function normally, and even convince us that we're losing our minds. And frustratingly, it often gets mixed-up with -- and even leads to -- other related psychological conditions, like substance abuse and personality difficulties.
Anxiety has without question become a fixture of modern life. Reported levels of anxiety have been on the rise since the end of World War II, and there is evidence that anxiety disorders now constitute the most prevalent mental health problems worldwide. And there very well may be something to modern life that's causing anxiety -- or the impression of it -- to reach epidemic proportions.
Indeed, studies show (at least in the UK) that, from 1998 to 2008, diagnoses among general practitioners have fallen, but that anxiety symptoms have increased. It's quite possible that GPs are reluctant, for whatever reason, to label people with anxiety disorders.
More clearly, it's obvious that we're learning a lot about anxiety -- and what can be done about it.
What are the different kinds of anxiety disorders?
Anxiety disorders affect about 40 million American adults, and over two million Australians. Women are 60 per cent more likely than men to experience an anxiety disorder (excluding obsessive compulsive disorders). Non-Hispanic blacks are 20 per cent less likely, and Hispanics 30 per cent less likely, than non-Hispanic whites to experience an anxiety disorder during their lifetime. As for teens, about 8 per cent have an anxiety disorder.
Anxiety is an umbrella term that encompasses a number of related disorders.
Generalized anxiety disorder (GAD) is the most common, affecting about six per cent of Australians over the course of their lifetimes. Psychologists describe it as a more-or-less constant state of worry and anxiety that's out of proportion to what's actually going on in a person's life.
Symptoms of GAD include increased heart rate, "jelly legs", tingling in the hands and feet, hyperventilation, dizziness, feeling sick, tension headaches, hot flushes and shaking (just to name a few -- anxiety manifests differently for different people). In addition, anxiety makes people think they're going mad or that they're about to lose control. They think they might die, or that they're going to be sick. GAD sufferers also feel as though things are speeding up and slowing down, that they're detached from their environment and the people in it and that they want to run away and escape from the situation.
People with GAD tend to be unsure of themselves, overly perfectionist and overly conforming. A diagnosis of GAD is typically confirmed if certain symptoms are present on most days for a period of six months, including being on edge or restless, feeling tired, having difficulty concentrating, being irritable, experiencing muscle tension and disturbed sleep.
There's also panic disorder, a condition characterised by periodic episodes of anxiety or terror -- the dreaded panic attack. These can last from 15 to 30 minutes and can occur in nearly every other kind of anxiety disorder (though in those cases the attacks tend to be triggered by a specific event or cue). Symptoms include a rapid heartbeat, sweating, shakiness, shortness of breath, a fear of dying and even a fear of going insane. Some people experience limited-symptom attacks, which can be either residual symptoms after a major attack, or precursors to a full-blown attack.
The other four major classifications of anxiety disorders include all phobic disorders (like the fear of flying, stage fright and claustrophobia); obsessive-compulsive disorder (OCD); post-traumatic stress disorder (PTSD) and separation anxiety disorder. All these disorders can induce symptoms similar to GAD.
And in addition to the symptoms and feelings already described, individuals with anxiety disorders tend to have their lives ruled by avoidance, subterfuge, ritual (like locking and unlocking the door several times) and self-medication (like drugs, alcohol and even self harm). Anxiety sufferers are also at an increased risk of suicide. These disorders can also induce related medical conditions, like migraines, obstructive sleep apnoea, irritable bowel syndrome, chronic fatigue syndrome and premenstrual syndrome.
What causes it?
Anxiety disorders are caused by a combination of biological, psychological and environmental factors. Some people are simply more vulnerable to stress, whether it be on account of biological or socially-learned predispositions.
Looking at it biologically, nearly 50 per cent of people with panic disorders and 40 per cent with GAD have close relatives with the disorder -- though that doesn't prove genetic causation. Other risk factors include gender, age, personality factors (like shyness and an intolerance for uncertainty), family history and dynamics (there's a strong correlation between a parent's fears and those of children -- fears that are learned and reinforced), social factors (like cultural expectations and conditioning -- more on this in just a bit) and traumatic events (like child abuse, wartime experiences and surviving a near-death experience).
Looking at the brain itself and the most proximate causes, anxiety disorders are the result of biochemical factors, like an imbalance of certain neurotransmitters, including gamma-aminobutyric acid (GABA), serotonin, dopamine and epinephrine. Serotonin is particularly important to feelings of well being; deficiencies are highly related to anxiety and depression. Stress hormones, like cortisol, also play a role.
People with anxiety disorders may have an amygdala -- the part of the brain that regulates fear, memory and emotion -- that's highly sensitive to new or unfamiliar situations, prompting an exaggerated stress response. The amygdala coordinates these resources with heart rate, blood pressure and other physical responses to stressful events.
There's also the hippocampus to consider, the part of the brain that encodes threatening events into memories. And in fact, studies show that this part of the brain is smaller in some people who were victims of child abuse or who experienced military combat.
As for the bout of anxiety itself, whether it be GAD or an outright panic attack, it's the perception of a sense of danger that sets off the sympathetic nervous system -- a preparation for something that (arguably) never comes. During this fight-or-flight response, catecholamine hormones, like adrenaline or noradrenaline, get the body ready for violent physical action.
How can anxiety be treated?
Typically, anxiety disorders are treated with a combination of talk therapy, like cognitive behavioural therapy, and an antidepressant medication. It's a one-two punch that -- in conjunction with a bit of physical activity, adequate rest and good nutrition -- works well for lots of people.
This is what anxiety-sufferer Clair Eastham told the Guardian:
I contacted [Anxiety UK], and it was amazing to find that I wasn't alone, that in itself helped a bit. But they also gave me good advice. They recommended I start using exercise to take the edge off the adrenalin, and they suggested Cognitive Behavioural Therapy (CBT). I had 10 sessions, which was all I could afford, and it changed everything. It wasn't only that I was able to be honest about how I was feeling, that off-loading on to someone who understands, as opposed to someone who just thinks 'Oh, snap out of it', felt so good. The therapy gave me the tools I need to rationalise. You have to commit to CBT; you have to put the time aside. But it does work. I still have bad days, but at least now I have a strategy.
CBT works by teaching people to challenge the negative voices in their head. It can have as much as an 80 per cent success rate, especially when combined with psychopharmaceuticals, like antidepressants. Other types of medications are also sometimes prescribed, like benzodiazepines, azapirones, beta blockers or atypical antipsychotics. In some cases, drugs like Valium and Sertraline are used.
Anxiety UK has said that sufferers should avoid sugar, caffeine and alcohol, all of which can make a person more jittery. Even a bit of humour can help.
The University of Maryland Medical Center prepared this chart showing the various treatment options:
It's also worth noting that anxiety isn't something that can be eradicated. As GAD sufferer and author of The Monkey Mind Chronicles Daniel Smith says, we should work to alleviate, not cure:
Anxiety isn't a condition like pneumonia or chicken pox. It isn't something you can eradicate. It's a state of being, a coloration in the way a person thinks, feels, and acts. It isn't a disorder, necessarily, though it can be exquisitely painful and it does sometimes stem from trauma. What it is, is a state of mind. It can be reduced, in some cases radically, but it never totally goes away.
So are we living in the age of anxiety? Has it truly reached epidemic proportions? The numbers are not clear on this, especially considering that anxiety disorders have only been formally diagnosed in recent times.
As Marcia Angell noted in her New York Times article, "Epidemic of Mental Illness: Why?", a survey of randomly selected adults conducted between 2001 and 2003 showed that "46% of participants met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives". Anxiety disorders in particular take up a huge swath of mental health issues, from debilitating panic attacks to the fear of spiders.
What's more, anxiety is hardly a modern invention. Spinoza talked about our enslavement to what he called the "dread". Kierkegaard wrote about it in his work, The Concept of Anxiety, as did Freud in The Problem of Anxiety. Kierkegaard, one of the most anxious persons to have ever lived, described it this way:
And no Grand Inquisitor has in readiness such terrible tortures as has anxiety, and no spy knows how to attack more artfully the man he suspects, choosing the instant when he is weakest, nor knows how to lay traps where he will be caught and ensnared, as anxiety knows how, and no sharpwitted judge knows how to interrogate, to examine the accused, as anxiety does, which never lets him escape, neither by diversion nor by noise, neither at work nor at play, neither by day nor by night.
Specific conditions, like post traumatic stress disorder, have likely existed since the dawn of time. Combat stress reaction, an anxiety disorder that's a precursor to PTSD, was referred to as "shell shock" during World War One and as "combat fatigue" during World War Two. As for people who lived through bombing campaigns or genocides, one can only imagine the degree of lingering anxiety they experienced. We have it relatively good, making the whole "anxiety epidemic" claim all the more perplexing -- though anxiety diagnoses skyrocketed in the immediate aftermath of 9/11; some 4 million Americans were diagnosed in the months following the tragedy.
A disease of privilege?
But that's not to say our lives aren't full of anxiety-inducing triggers. As noted, there are strong learned and environmental components to anxiety, some of which may be brought about by our modern, affluent society; it's all an issue of relativity.
Modern life, argues Bruce E. Levine in his Alternet article "How Our Society Breeds Anxiety, Depression and Dysfunction", may make us more susceptible to these sorts of mental issues. Today's employees are disengaged from their jobs (upwards of 30 per cent), students are debt-ridden, recent graduates are underemployed and many struggle to cope with social isolation. There are increased feelings of helplessness, hopelessness, passivity, boredom, fear, isolation and dehumanisation, all "culminating in a loss of autonomy and community-connectedness".
Indeed, social factors are contributing to the problem. Numerous studies have reported a significant increase in anxiety levels in children and university students in recent decades -- anxiety that has been linked to a lack of social connection and the sense of more threatening environments.
Additionally, socially alienated populations experience higher levels of anxiety. In a study of Mexican adults living in California, native-born Mexican Americans were three times more likely to have anxiety disorders than those who recently immigrated to the US. The longer the immigrants lived in the US, the greater their risk for psychiatric problems. According to the researchers, traditional Mexican cultural and social ties may be protecting recently arrived immigrants from mental illness.
In the UK, the recent depression may have made things worse. Nicky Lidbetter, the chief executive of Anxiety UK, has said that,
Since the downturn, we've seen increased calls to our helpline and increased requests from people wanting to access support services. What we are finding is that people who might ordinarily have managed their anxiety quite well have been tipped into new territory by being made redundant or having to adapt to new life circumstances.
Another area where anxiety is being diagnosed more readily is in the military. A study revealed that 218,000 incidents of anxiety disorders were diagnosed among the active-component of the US Armed Forces over the course of a 13 year period. That's about 117 per 10,000 person-years. For the Army this is a serious issue. As Colonel William Corr has noted:
In the U.S. Armed Forces, mental disorders, of which anxiety disorders are a subset, are a leading cause of morbidity, disability, healthcare service utilization, lost duty time, and attrition from military service. Incidence rates of mental disorders diagnoses overall and anxiety disorders in particular have increased sharply among U.S. military members during the past 10 years.
According to the Institute of Medicine, PTSD affects between 13 to 20 per cent of US military service members who have served in Iraq or Afghanistan since 2001.
Given all this, it's not clear if we're in the midst of an anxiety epidemic. But it's obvious anxiety is a serious health problem -- one that public health officials should definitely keep their eye on.