How to Diagnose Acute Anxiety

What happened to all of the neurotics? Nothing except a name change. Now, they have anxiety disorders. Actually, they all had anxiety before, called, neurotic anxiety and they were named for the defense mechanism that they used to control (defend against) the anxiety. They still do, but the names have been changed to refer to more descriptive categories. Before discussing these categories, it is important to make sure that the construct of anxiety is understood.

First of all, the etiology is a combination of genetic predisposition and learning. There is a demonstrable heritable component that predisposes toward emotionality through the mammalian kingdom that has been demonstrated as far down the phylogenetic ladder as mice. People are no exception. Learning, however, particularly in the acute syndromes, plays a significant part.

Anxiety can be construed as having two components, a physical response of the body and a mental/feeling component. The first component comprises physical reactions that are visible to observers and, therefore, are technically signs of a disorder. The mental part is inferred from behavior or the verbal reports of the people afflicted and, therefore, have the status of symptoms. The distinction is often murky in psychiatric disorders, however.

The physical reaction is mediated by the autonomic nervous system and is predominantly a generalized sympathetic response; that part of the autonomic nervous system that prepares the body for fight or flight. That is it makes the body ready for effective physical exertion by putting its resource into the muscles and out of the gut. Heart rate increases, blood flow changes and the body gets ready to run (flight) or attack (fight). Unfortunately, in anxiety, it does neither. When it is prepared for action and there is no action there is a problem. That problem is fear or anxiety.

The mental component is a very uncomfortable condition; it reflects the body's need to do something it's not doing. The urge to run and get away is fear, if you know what you are running from; it's anxiety if you don't. The urge to fight is anger if you have someone you want to attack; it's anxiety if you don't. Anxiety is often thought of as akin to fear without knowing what you are afraid of. And this is actually an accurate way of looking at it. The anxious person is, indeed, afraid and the problem is that the fear is so strong that even thinking about what it is that is feared feels literally unthinkable; so it is. You can't think about it enough to recognize what it is. It's a thought, or a perception, or, in some cases, a memory, but you are running from it - mentally. The catch is, that it's hard to get away from something if you don't know what it is you are trying to get away from. This leaves you with a constant need to escape but no place to go.

The bodily signs of anxiety are pretty much what happens when you run or attack. In the extreme form, it's called panic. You breathe harder, feeling a shortness of breath; your heart races or pounds and, sometimes you feel chest pain. You sweat, and your muscles do move, but instead of getting somewhere, you tremble. Sometimes, if it's intense enough, you feel dizzy and may even faint. Internally, you know you are afraid, and look for something to fear, and, given the strange way your body is reacting, you fear losing control, going crazy or even dying. Other signs and symptoms can be nausea or vomiting, chills or hot flashes, feeling apart from your body, and numbness in parts of the body. These signs and symptoms are considered a panic attack when four or more of the above are present.

In panic attacks, these symptoms build relatively quickly, generally in less than ten minutes, but they can last longer than that, depending on what triggered them. No one can feel that way for very long. These are acute events, or attacks. However, there are people who are anxious nearly all the time or always when in specific situations. The symptoms of this chronic anxiety are similar in kind to those above that are experienced during an acute panic attack, but less in degree. The folks afflicted with anxiety, panic attacks or chronic are, for the most part, what we used to call neurotics. Now, we have welter of diagnostic categories for them.

Panic disorders are very interesting psychologically, because no matter what the real stimulus may be, the sufferers often experience the fear as a fear of having panic attacks. This usually protects them from the situations that are really anxiety provoking for them. For example, they don't leave the safe confines of their homes (agoraphobia). This prevents them from encountering the feared stimuli and allows them to avoid, and, therefore, not face the threats that are responsible. This defense can be so effective, that the people can entirely avoid having an actual panic attack (although there is always some chronic anxiety). This is called Agoraphobia without a History of Panic Attacks. Obviously, that implies that there would be a category of Agoraphobia with Panic Disorder. (Interestingly, there are no such diagnostic categories as just Panic Disorder or just Agoraphobia.)

There are two other categories of acute symptoms within the anxiety disorders category, but they do not involve full blown panic attacks. They do involve specific limited symptoms that are similar, however. These are the Acute Stress Disorder and its big brother, the politically famous Post Traumatic Stress Disorder. Both of these involve a (usually) delayed reaction to a severe stressor, a traumatic event that involved serious physical injury or threat to life or physical integrity of the body. The event may have happened to the person or closely witnessed by the person.

The difference between the Acute Stress Disorder and the Post Traumatic Stress Disorder is the length of time it exists. The Acute Stress Disorder is, by definition, acute. It must start and stop within four weeks of the traumatic event. It also has to be disruptive to the person's life and last at least two days or it is demoted to an adjustment disorder, the baby brother of this spectrum that does not qualify as an anxiety disorder. Adjustment disorders are also considered the proper diagnosis if the symptoms, regardless of length of the illness, do not cause serious impairment. If the symptoms meet the criteria for Acute Stress Disorder and last more than a month the diagnosis of Post Traumatic Stress Disorder becomes proper. In fact, PTSD cannot be diagnosed within one month of the onset of symptoms.

The rest of the diagnoses within the anxiety disorders category involve chronic, long term anxiety symptoms, with or without specific defenses against them. I should mention that there are purely physical causes for excessive anxiety, such as some illnesses or drugs. When this type of reason can be identified, the anxiety disorder is diagnosed as secondary to that specific cause and not considered a primary diagnosis.

Why do these diagnostic categories matter? The usual expected answer is that they direct treatment, and that would be a good answer; it just isn't exactly true. To begin with, although there are psychological and pharmacological treatments, they have limited success and the treatments need to be individualized to such an extent that therapy based on the diagnostic categories has not proven to be very useful. Still there have been some successes, just not consistent. Nevertheless, there are good reasons for maintaining strict diagnostic categories. Comparisons across regions and countries for statistical and research purposes could not, otherwise be performed. There may not be any hard and fast therapy rules based on diagnosis, but maintaining uniform rules for the categories can help lead to this end.

The next part will deal with the chronic anxiety disorders and a little about treatment.