Fear is a basic human emotion that has been crucial for survival both as an individual and as a species. Anxiety is the normal reaction of an organism to a stressor which may be external - or internal. The anxiety reaction generally has two components - one physiological and the other psychological, and both are mediated largely by the adrenergic (adrenaline and norepinepherine - the key components in the "Fright, Flight or Fight" response) neurotransmitter system^1..

"Anxiety disorders" is a term used to describe unbalance in an individual's feelings or 'states' of anxiety, that is, the levels of tension, nervousness, distress, or uncomfortable arousal which they perceive.

Edward Munch (1863-1944) vividly captured the terror often felt by persons with anxiety disorders in his painting "The Cry" shown above - (It is often translated as "The Scream").

As in all things, scientists and researchers love to fragment things in order to better study them, and accordingly categorise them, however, it is usual to find that an anxiety disorder extends throughout the whole person, at many levels, so that many aspects of function will need to be addressed to restore balance.

Firstly, let us look at the five main categories of "anxiety":-

1. Phobias
   Persistent, irrational, and disruptive fears of a specific object, activity or type of situation. A fear can be classified as a phobia when it is substantially greater than what seems justified or when it has no basis in reality. Generally, people with phobias are aware of their fears being an irrational response, and wish to overcome them, but have a great dealing of difficulty in doing so. Phobias can be simple, social, or complex - as in agoraphobia.
   a). Simple phobias encompass the irrational fears of objects (e.g., spiders, snakes, high places, 'the dark' etc.) Simple phobias are actually much less common than social or complex phobias.
   b). Social phobias cover the extreme fear of being criticised by other people leading to avoidance of social interaction involving groups of people, meeting new people, speaking in public - or doing anything which might result in criticism of any kind.
   c). Agoraphobia is the fear of open, or public places. It accounts for around 60% of all phobias. Statistically, the majority of agoraphobics are female, and the problem usually begins to develop in adolescence or early adulthood. In extreme cases of agoraphobia, the person is unable to leave their home.
2. Panic Disorder
   Panic disorder is characterised by brief, abrupt and unprovoked, recurrent episodes of intense and uncontrollable anxiety. The person feels suddenly apprehensive or terrified, and will usually experience difficulty with breathing, heart palpitations, dizziness, sweating and trembling. Often the person fears losing control of themselves. Or 'going crazy'.
3. Generalised Anxiety Disorder
   Called this because the cause is difficult for the person to identify and trace to any specific problem, hence 'general', persistent, and often debilitating high levels of anxiety that can last any length of time. Physical symptoms are often quite prominent in this form of anxiety.
4. Stress Disorder
   Presents as extreme reaction to a highly stressful event or situation, and is often linked to adjustment disorders or the mere fact of coping with change. Categories of stress disorder include posttraumatic stress disorder and acute stress disorder.
   a). Posttraumatic stress disorder involves the reenactment of a traumatic event, including recurrent and painful memories, nightmares and flashbacks that are so strong that the person believes he or she is reliving the event. The event may be participation in war, or exposure to a disaster such as earthquake, flood or fire, or serious accident. Some victims are so plagued by these recurrences that they become apathetic and detached.
   b). Acute stress disorder is characterised by acute, brief, reactions to stress, which directly follow a traumatic event and last fewer than four months. The sufferer may experience a sense of detachment from the physical and social worlds, including distortions or other changes of perception and disturbances of memory.
5. Obsessive-Compulsive Disorder
   OCD consists of unwarranted, persistent thoughts and irresistible impulses to perform a ritual to relieve those thoughts.
   a). Obsession - unwanted images or impulses that the individual is unable to suppress. Obsessives are usually unhappy about the obsession and being unable to keep it out of their minds.
   b). Compulsion - irresistible impulses to perform a relatively meaningless act repeatedly and in a specific manner. The sufferer does not cherish or enjoy the ritualistic behaviour and will often view the bahaviour as foreign to their personality. They are aware of the absurdity of their behaviour, but are nevertheless unable to stop it. Someone with a compulsion to wash their hands for example, may perform this ritual several hundred times a day - in addition to being time consuming, the compulsions are often costly to the person's wellbeing. Other common compulsions are counting things to make sure that they are all there, checking the placement of objects and checking that appliances are turned off.

Some MRI scans have revealed over-activity in the locus coeruleus (a part of the brain important in triggering a response to danger) in people experiencing anxiety. A recent study using dual-probe microdialysis by Pudovkina, Kawahara, de Vries, and Westerink, confirms the release of noradrenaline in the locus coeruleus and prefrontal cortex^5.. Further, this site in the brain is a centre of control for circadian rhythms as revealed in a study by Aston-Jones, G; Chen, Sheng; Zhu, Yan; Oshinsky, ML. In this study using trans-synaptic retrograde tracing it was found that a prominent indirect projection exists from the suprachiasmatic nucleus to the noradrenergic nucleus locus coeruleus (LC), a brain arousal system important in behavioral state regulation^6..

Other studies have detected abnormalities in the amygdala, a part of the brain that regulates fear, memory, and emotion and coordinates them with heart rate, blood pressure, and other physical responses to stressful events.

 So, What Really Causes Anxiety Disorders?

An individual's environment, genetics, biochemistry, history - including familial history, and psychological profile all appear to contribute to the development of anxiety disorders. Most people with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the 'normal' or average population.

As you may have guessed, up to half of the people diagnosed with panic disorder have close relatives in whom the disorder is present, and about 20% of people with generalized anxiety have relatives with the same disorder. (About half of general anxiety disorder patients also have family members with panic disorder, and about 30% have relatives with simple phobias.) Obsessive-compulsive disorder is also strongly correlated to a family history of the disorder. Researchers are searching for specific genetic factors that might contribute to an inherited risk.

A 1999 study identified a possible genetic defect in OCD patients that affects serotonin, a neurotransmitter which appears to be important in anxiety disorders. Earlier, researchers identified a gene that produces lower amounts of serotonin in people who have personality traits that include anxiety, anger, hostility, impulsiveness, pessimism, and depression.

Other studies have identified a genetic defect that affects dopamine, another important neurotransmitter, which appears to cause a syndrome that includes migraine headaches, anxiety, and depression.

At an April 2001 meeting of the Human Genome Organization, Dr. Xavier Estevill, head of medical and molecular genetics at the Durani Rynals Hospital in Barcelona reported that a study he had conducted among a random sample of people with anxiety disorders, 97% had a duplication of genetic material on chromosome 15 -- compared with 7% in a comparison group of healthy people^8..

Given that various findings are pointing toward a genetic predisposition as a primary cause of anxiety disorder, it should be remembered that not everyone who is predisposed toward anxiety will develop symptoms severe enough to seek help, however, there are triggers which may lead to anxiety disorders in susceptible individuals.

"Children naturally have fears; it's part of growing up," says Deborah Beidel. "But when it stops being developmentally appropriate, then it's a problem. If fear is keeping a child from doing things that he should be doing--participating in school, playing, having friends, sleeping away from parents--then it's time to get help.^10."

Children are most commonly affected by the following 5 anxiety disorders. R. Lindsey Bergman, PhD, associate director of the UCLA Child and Adolescent OCD and Anxiety Programme, defines them as problems when they disturb family life^11.:

Researchers seldom find a single factor that causes a psychological phenomenon. As each new insight into the workings of the human mind and body comes to light we obtain an increasingly detailed, more whole picture, enabling us to approach amelioration in a more wholistic manner, treating the whole person instead of just the symptom(s).

The best interventional option for you will depend on your specific diagnosis, symptoms, medical and familial history, and any co-existing physical or emotional problems.

Drugs listed in the MIMS (An Australian Pharmaceutical Publication of approved drugs utilised by doctors) for anxiety are as follows:- Aldazine, Alepam, Amytal Sodium, Antenex, Ativan, Buspar, Chlorpromazine Injection BP, Deptran, Diazemuls, Diazepam Injection, Dothep, Ducene, Frisium, Kalma, Lesotan, Melleril, Murelax, Neulactil, Prothiden, Serepax, Sinquan, Stelazine, Surmontil, Valium, Xanax.

For Panic Disorders:- Aropax, Ducene, Kalma, Xanax and Zoloft.

Until recently, the anti-anxiety drugs known as benzodiazepines were the primary medications for anxiety. Increasingly, antidepressants, particularly the selective serotonin-reuptake inhibitors (SSRIs), are being used as the initial treatment. They are proving to be effective, physically nonaddictive, and to have relatively 'minor' side effects.

Many standard antidepressants require two to four weeks, and sometimes up to 12 weeks before they are fully effective.

People who take them may also experience a temporary period of increased anxiety.

Antidepressants

These drugs are the first-line of treatment for obsessive-compulsive disorder, and seem to reduce symptoms by 25% to 35% in about half of all patients. However, people with OCD and hoarding or compulsive behaviors may not respond as well to SSRIs as do those without these symptoms. In one study of children with OCD, Paxil therapy was associated with an apparent decrease in the size of the thalamus, a portion of the brain that is greatly involved with serotonin and may be enlarged in some people with OCD. SSRIs are also less effective in OCD patients with tics, for whom small doses of drugs known as neuroleptics may be helpful.

Zoloft and Luvox are used in treating patients with panic disorder. Some SSRIs appear to be of help to people with phobias, including agoraphobia and social phobias. However, relapse is common in social phobia patients even after prolonged treatment. Combining medications with cognitive-behavioral therapy can help prevent relapse.

Many SSRIs are prescribed for PTSD including fluvoxamine, sertraline, citalopram, and paroxetine.

According to the MIMS, the following side-effects have been reported with use of SSRIs:
Common Side Effects: Asthenia ("general weakness or debility"), headaches, malaise; agitation, anxiety, dizziness, insomnia, nervousness, somnolance, abdominal pain, anorexia, constipation, diarrhoea, dry mouth, dyspepsia, palpitatyions, tachycardia, sweating and terror.

Less common side effects of these drugs include: Ataxia (inability to coordinate voluntary muscle movement), confusion, extrapyramidal symptoms (motor symptoms external the motor system), hallucinations, hypotension, postural changes, Atralgia, myalgia, rashes, dermatitis, delayed ejaculation.

Rarer complications include: Convulsions, mania, liver dysfunction, photosensitivity, galactorrheoa.

Designer Antidepressants. A number of newer antidepressants that target other neurotransmitters alone or in addition to serotonin include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron).

Combined Drug, and Non-Drug Treatment Options
Anxiety Disorder Benzodiazepines; buspirone; antidepressants, particularly extended release venlafaxine (Effexor) and some tricyclics Cognitive-behavioral, interpersonal therapy, stress management, biofeedback .
Panic Attacks SSRIs, benzodiazepines, tricyclics, MAO inhibitors, potentially, anticonvulsants Cognitive-behavioral therapy, including breathwork and nutrition.
Phobias Benzodiazepines, beta-blockers, SSRIs Cognitive-behavioral therapy (desensitization therapy), hypnosis.
Obsessive Compulsive Disorder SSRIs as first choice, except if tics are present (neuroleptics for tics), clomipramine (a tricyclic), MAO inhibitors for those who do not respond to other drugs Cognitive-behavioral therapy (Exposure and response prevention).
Post-traumatic Stress Disorder Antidepressants, particularly the SSRI sertraline, clonidine Cognitive-behavioral therapy (Group therapy).

Note: For anxiety disorders, the most common treatments prescribed are usually combinations of drugs and behavioral techniques

• The ability to shift attention
• Helping the mind move from idea to idea
• Allowing the mind to see options
• Cognitive flexibility (helps you go with the flow)
• Adaptability
• Ability to cooperate

One can only wonder at the long term implications of such a procedure and its effect on interrelations with others.

Psychotherapeutic and Other Non-Drug Approaches to Anxiety Disorder

A healthy, balanced lifestyle that includes exercise (movement - for the human body was designed to move), adequate rest, and proper nutrition can greatly help to reduce the impact of anxiety attacks. Rhythmic aerobic and yoga exercise programmes lasting for more than 15 weeks have been found to help reduce anxiety, probably due to the increased oxygenation of tissues - especially brain tissues, and production of endorphins. Strength, or resistance training alone does not seem to help anxiety.

As in all matters concerning health, personal responsibility for the maintenance of good health rests with the individual.

The goal of cognitive-behavioral therapy (CBT) is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. CBT works on the principle that the thoughts that produce and maintain anxiety can be recognized and altered using various techniques, thereby changing the behavioral response and eliminating the anxiety reaction.

A number of CBT approaches have been designed to treat both the general symptoms of anxiety and specific disorders. In one study of panic disorder patients, either CBT or a tricyclic antidepressant alone or in combination was as effective as short-term and maintenance therapy. After discontinuing treatment, however, CBT alone offered the best chance for a persistent response. Other studies have also reported similar benefits. CBT alone may be as effective as medications for children with OCD. Cognitive-behavioral therapy may even help people with post-traumatic stress disorder. CBT used in group therapy for children with PTSD may be especially helpful.

Treatments are equally effective in men and women. Anxiety disorders are chronic, however, and recurrence is common. Some studies indicate, in fact, that between 30% and 82% of people with panic disorder and phobias have a recurrence of attacks at an average of nine months even after successful short-term therapy. (Women are at much higher risk for recurrence of panic attacks than men.) Medications, then, are also generally recommended for most patients. There may be exceptions.

Basic Cognitive Therapy Techniques. Treatment usually takes about 12 to 20 weeks. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations.

• First, the patient must learn how to recognize anxious reactions and thoughts as they occur. One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. An OCD patient, for instance, may record repetitive thoughts.
• These entrenched and automatic reactions and thoughts must be challenged and understood. Again, using the OCD example, one approach is to record and play back the words of the repetitive thoughts, over exposing the patient to the thoughts and reducing their effect.
• Patients are usually given behavioral homework assignments to help them change their behavior. For example, a person with generalized social phobia may be asked to buy an item and then return it the next day, observing as he or she does so the unrealistic fears and thoughts triggered by such an event.!!
• As the patient continues with self-observation, he or she begins to perceive the false assumptions that underlie the anxiety. For example, OCD patients may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is not necessary or even useful.
• At that point, the patient can begin substituting new ways of coping with the feared objects and situations.

• Systematic desensitization is a specific technique that breaks the link between the anxiety-provoking stimulus and the anxiety response; this treatment requires the patient to gradually confront the object of fear and is especially effective for simple phobias, social phobias, agoraphobia, and post-traumatic stress syndrome.

• Relaxation training.
• A list composed by the patient that prioritizes anxiety-inducing situations by degree of fear.
• The desensitization procedure itself, confronting each item on the list, starting with the least stressful.

Exposure treatment purposefully generates anxiety by exposing the patient repeatedly to the feared object or situation, either literally or using imagination and visualization. It uses the most fearful stimulus first. (This differs from the desensitization process because it does not involve relaxation or a gradual approach to the source of anxiety.)

Exposure treatments are usually either known as flooding or graduated exposure:

• Flooding exposes the person to the anxiety-producing stimulus for as long as one to two hours.
• Graduated exposure gives the patient a greater degree of control over the length and frequency of exposures.

In both cases the patient experiences the anxiety over and over until the stimulating event eventually loses its effect. Combining exposure with standard cognitive therapy may be particularly beneficial. This approach has helped certain patients in most anxiety disorder categories. In one study, it even helped prevent PTSD from developing in motor-vehicle accident survivors with acute stress disorder. (The results of this study, however, are not necessarily applicable to other trauma sufferers, such as rape victims.)

Phobias can often be treated successfully with modeling treatment:

• The therapy typically uses an actor who approaches an anxiety-producing object or engages in a fear-provoking activity that is similar to the patient's specific problem. Either a live or video-taped situation may be used, although the live model is considered to be more effective.
• The patient observes this event and tries to learn how to behave in a comparable manner.

Eventually, so-called "virtual reality" may prove to be a very useful modeling tool. This technology employs computer-generated images and special headgear to realistically simulate a natural environment and allow interaction with it. In one case, a psychologist used virtual reality to cure a woman of arachnophobia (fear of spiders). More research is needed.

  Other Forms of Psychotherapy

Other forms of psychotherapy, commonly called "talk" therapies, deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention, and psychoanalysis. All work is done during the sessions. Some experts believe that such therapies might be more useful for generalized anxiety, which may require more sustained work to process and recover from early traumas and fears.

After a thorough history and psychometric assessment including a QEEG, an individualised programme will be devised aimed at restoring balance in the autonomic nervous system, and outlook. These include a combination of any of the following:- education and counselling, diet and nutrition, breathwork, biofeedbackand/or neurofeedback training, heart rate variability training, meditation and movement exercises.

Consultation is by appointment only, for further information please contact:-

Telephone:
Sydney +61 2 9637 9998
Facsimile:
Sydney +61 2 9637 8799

Address:
P.O. Box 47
Harris Park NSW 2150
Australia