Chronic Anxiety Disorders

Would you rather be obsessive-compulsive or anxious? As strange as that may sound, that's the choice that some people's psyches make at some unconscious level. It's not a particularly good choice with which to be presented for several reasons. One is that it doesn't actually work very well; that is, the obsessive compulsive symptoms aren't really very effective at controlling the anxiety and, usually, there is enough left over for the appearance of other symptoms, including the discomfort of anxiety itself. But let's back up and review what anxiety itself is, and what obsessive and compulsive symptoms are.

Briefly for now, remember that anxiety itself is a form of fear without an accurately identifiable object of which you are afraid. The stimulus for the fear is usually some threatening internal state, a thought or an impulse that we don't want to recognize, thus causing the physiological effects of arousal by the sympathetic nervous system and the psychological need to flee or escape. This general anxiety usually manifests as excessive worry over many different issues, worry about everything there is to worry about, often changing and never truly realistic. This will be described later in this article in greater detail. Suffice it to say that anxiety can be thought of as the psychic equivalent of pain. By definition, it is a state of severe discomfort. Therefore, just as we seek ways to distract ourselves from unremitting physical pain, we develop defenses that deflect or reduce the anxiety. And these have, historically been called defense mechanisms, a name that describes their purpose. When these defense mechanisms are disruptive to the person's life, we think of them as symptoms of mental disorder.

To throw in a touch of honesty, the current tendency is to think in terms of behavioral description and not in terms of the utility or purpose of the symptoms, which is a more dynamic approach. This shift to operational definitions has served a good purpose in providing greater uniformity for diagnostic criteria and, as a result, much more comparable diagnoses from region to region and from time to time. In turn, of course, this is a boon to epidemiologic description and research. However, I feel a touch of interpretive flesh on the bones of description also serves a purpose, at least in generating hypotheses and understanding more about the people we are discussing. Therefore, I shall describe the symptoms of obsessive-compulsive disorder in terms of their psychological utility as well as their simple description.

Obsessions, simply, are intrusive thoughts. They can be ideas, impulses, images, words, phrases, or song stanzas, but they are persistent, annoying, excessive, uncontrollable and unwanted. In addition, they make no sense to the person who has them, or at least serve no rational purpose. When they are intrusive and senseless, they are termed ego dystonic. They can have an obviously tangential relation to something real in the individual's life, but they do not serve any straightforward purpose even so, for example internally repeating the first three items on your shopping list, even after you have purchased them. More often, though, they make even less sense than that to the person, for example repeated thoughts about harming a loved one, or suddenly blurting out a string of obscenities at your church social, or pictures of sexual behavior that are utterly inappropriate and incredibly unlikely. These thoughts are not only mysterious and senseless, but possibly abhorrent. Other common types of obsessions are groundless worries over illness, careless and dangerous behaviors, DidI turn the oven off? and possible disasters that are highly unlikely (being wiped out in a law suit for some event you don't remember, or being beaten to a pulp for some imagined insult that you might have made).

An important feature of these thoughts is that the individual is aware that they are products of the self, not externally imposed by some mysterious means. That latter belief, called thought insertion is a delusion and a sign of a more serious thought disorder. Usually, but not always, the individual realizes that they are groundless and senseless, but cannot control them, nevertheless. If the person is an adult, it is part of the diagnostic criteria that the symptoms are recognized, at least at some point, as excessive or inappropriate. This is not necessary for the diagnosis in children, owing to the possibly lower level of analysis necessary for that insight. However, even in adults there are some sufferers with what is called simply, poor insight, who often do not see the irrational nature of the thoughts. If they never do, at any point of the disorder, it may well be a sign of a more serious or concomitant disorder.

I promised some explanation of the purpose of these symptoms. It's coming. First, though, what is a compulsion? The definition of compulsions is relatively simple. They begin with thoughts that are closely related to obsessional thoughts; the difference is that these thoughts involve an imperative need to perform some act. The act, once performed, completes the definition of a compulsion. As in obsessions, the act is repetitive, disturbing, apparently senseless, and virtually uncontrollable. If the act is resisted, the compulsive individual experiences anxiety that can become overwhelming until the act is performed. The compulsive act is not one that, in and of itself, provides pleasure; it provides relief from anxiety.

The most common kinds of compulsive behaviors involve irrational or highly excessive acts of protection (washing, locking doors, checking, praying), ordering (counting, organizing, cleaning), or obtaining meaningless assurances from others (requesting, pleading, demanding). The theme of these is some form of controlling the essentially uncontrollable. For example, Howard Hughes would have employees prepare his path with tissue paper, open doors for him (or he would open them, wrapping the knob in tissue so that his hand never touched it), and generally protect him from contamination ("germs"). Nevertheless, he would never brush his teeth and the caries became so bad that he would sit in his room, watch his old movies, and chip off parts of his teeth, night after night.

Other kinds of compulsions have no apparent meaning at all, such as counting or repeating rituals, either simple or complex. The acts are not only pointless or ineffective, they are troublesome and often destructive. For example, hand washing often leaves them raw and painful. Some protect against obsessive thoughts, such as the person who cannot stop thinking about screaming out insults at his boss may, instead sing endless verses of 100 bottles of beer on the wall (quietly, one hopes). If the compulsive behavior is resisted, anxiety continues to mount until the act is performed.

Everyone has a touch of obsessive, compulsive, magical thinking or superstitious behavior. It is when these become disruptive to life that they take on the diagnosis of Obsessive-Compulsive Disorder. There is a moderate genetic component to the likelihood of receiving this diagnosis at some time in one's life. It is also more prevalent than previously thought with a lifetime prevalence in epidemiologic studies of approximately 2.5%. It usually begins in adolescence or young adulthood, but can begin in childhood. Its course begins significantly earlier in males than females (childhood or adolescence for males and young adulthood for females. Generally, it is a lifelong pattern with a minority of individuals showing progressive worsening of symptoms. Most of the time, however, it waxes and wanes in intensity (usually related to stress), occasionally, the course is episodic with periods of normalcy between episodes, but the disorder rarely remits permanently. Some neurologic disorders predispose to this condition, particularly Tourette's.

Earlier, I promised some mention of dynamic utility, so here it comes. First consider what gives people anxiety in the first place: threat of danger. If it's realistic and assessable danger, we fear it. If it is unknown danger, particularly that coming from our own thoughts or unacceptable impulses, we can become anxious. The danger is unrealistic, but threatening and part of the threat comes from the possibility of becoming aware of the thoughts. For example, Fred thinks of himself as so inadequate, that he knows something bad will happen to him. The world is dangerous and he is unable to cope with it. His feelings of inadequacy are so intense and troublesome that he cannot cope with them directly. Maybe if he makes absolutely sure that he turns off the oven and locks the doors, he can control the danger. At some level, of course, he knows that there is little danger of burning down his house or being robbed, particularly if he is careful. So he can be almost assured that he is safe. He knows his fears are way overblown. He can reassure himself of that. So, as long as he thinks that way, he can feel fairly reassured; his fears are groundless and, besides, he is making certain that he is doing something about it.

Similarly with intrusive thoughts. The student who is focusing on the thought that he could make an unacceptable fool of himself by yelling out obscenities in class, knows that he isn't really going to do that. His real fear may well be that he will say something stupid, because, underneath it all, he really thinks of himself as stupid. But if he focuses on being afraid of some symbolic act that he knows he really won't do, he can deflect the fear of making a fool of himself by concentrating on the mistake he won't make. And the obsessive thought is nearly never acted out. In some way, almost all of the ritualistic thoughts or behaviors are ways of deflecting anxiety that is stimulated by something unrecognized, and that the individual wants to keep unrecognized. Most such symptoms can be conceived of in this manner, that is as deflecting the truly threatening, anxiety provoking thoughts. Sometimes, it actually helps, but the price to the sufferer is high. That leads to the oversimplified question at the beginning of this article. What happens if you don't pay the price?

Generalized Anxiety Disorder

Poorly defended anxiety manifests as -- hold the phone -- anxiety. Anxiety about everything and nothing. Worry about pretty much anything there is to worry about, experienced more than half the time for at least six months. That's official for the diagnosis (the six months) but if it lasts six months, it's a very good bet it's going to last a lot longer than that. It is intensely unpleasant, creating tension, sleep disturbances, concentration or attention difficulties,* irritability, fatigue, restlessness, and simple unease. Not all of these are always present or necessary for the diagnosis, but they usually occur together.

Unfortunately, this state of chronic, excessive worry, sometimes free floating (that is without identifiable stimulus) and sometimes just attached to many different things in the sufferer's life, is common. Lifetime prevalence is about 5%. It is not incompatible with other diagnoses. In fact, it can be co-diagnosed with obsessive-compulsive symptoms or panic attacks, phobias, and a number of other categories. Depression is often concomitant, sometimes as a cause (primary), and sometimes as a result (secondary).

The last installment in this series will be treatment options. They are of some, but limited assistance.
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* It is interesting to note that difficulty in concentration and attention are ubiquitous symptoms in all of the anxiety and almost all of the affective disorders. As an editorial comment, this often leads to misdiagnosis of a primary attention deficit disorder in children and an overprescription of stimulants.