Nikki Tilford's first glimpse into her personal nightmare came 21 years ago as she was driving to her job at the University of Cincinnati. "It was like a thunderbolt inside of me. My heart just started racing and my first thought was that I was having a heart attack or a stroke," says Tilford. Everything seemed normal when she got to work, so she dismissed it as a bad morning. The next day, on the same stretch of parkway, it happened again -- only this time, when she got to work she couldn't stop shaking. Within months, she could no longer go to work at all.
Tilford couldn't leave the house without panicking, so other people did the grocery shopping and everything else that required going outside. Tilford's universe shrank to the dimensions of the townhouse she shared with her husband and young daughters, and even there, walking into certain rooms made her dizzy and started her heart pounding. Only at Christmastime did she force herself to venture out and shop for her family; the experience left her so emotionally drained she'd be in bed for days. She feared elevators, escalators, even taking a shower in her own home.
Tilford's doctor was concerned about her high blood pressure, but he insisted she didn't have an anxiety disorder. Her personality, he said, was too upbeat. In reality, she was suffering from panic attacks and later discovered she had agoraphobia -- fear of going out in public -- and generalized anxiety disorder, which often go hand in hand.
"With this kind of anxiety you're always in a boxing ring on the inside," she says. "It is a vise grip on your brain, and you will avoid that feeling at all cost."
Anxiety isn't always a bad thing. It can act as a natural alarm system to an immediate threat. It can motivate us to foresee problems and figure out solutions. The physical symptoms of fear -- a racing heart, sweaty palms, rapid breathing, butterflies in the stomach -- can produce the adrenaline boost you need to confront real danger. In other words, some anxiety is normal and even helpful. But if worry is as debilitating as Tilford's, it has surpassed its usefulness.
Ongoing, overwhelming worry not tied to specific events is called generalized anxiety disorder, or GAD. A mood disorder that afflicts almost seven million adults in the U.S. each year, GAD strikes an estimated five percent of adults at some point in their lives, according to the National Institute of Mental Health. People with GAD are beset by fears that are way out of proportion to any real dangers in their lives. The worries, in essence, take on a life of their own.
"It's not so much the things they worry about, it's the degree to which they worry," says David Spiegel, MD, medical director of clinical and medical programs at the Center for Anxiety and Related Disorders at Boston University. "The worrying is so excessive, distressing, and intrusive that it interferes with normal functioning. It's difficult or impossible to control the anxiety and focus on something else." That means that for people with GAD, Spiegel says, anxiety extends into every arena of life -- their relationships, their ability to work productively, and their capacity to enjoy themselves.
Many people suffered from heightened anxiety after the September 11 terrorist attacks, but experts say that's a normal response to extreme events; it is different from the sort of all-consuming dread that plagues GAD sufferers over things that are often mundane. However, the attacks and all that followed could have easily triggered generalized anxiety disorder in someone who was prone to it but hadn't yet experienced the symptoms, says Geralyn Lederman, a spokeswoman for the Anxiety Disorders Association of America. And those already diagnosed with anxiety disorder may find themselves feeling worse in highly stressful times.
Recognition on the rise
GAD usually affects the body as well as the mind. Its symptoms include unrelenting, exaggerated worry, restlessness, and fatigue as well as irritability, trouble concentrating, and insomnia. GAD sufferers may also experience muscle tension, headaches, stomach pain, difficulty breathing, dizziness, or hot flashes, among other physical symptoms. To be diagnosed as GAD, the symptoms must persist for at least six months, according to the Diagnostic and Statistical Manual of Mental Disorders.
Although experts are not sure whether the disorder is on the rise, they do say more people are being diagnosed with it. The disorder is being recognized, diagnosed, and treated more than before because there's a growing awareness of it within the medical profession, says psychotherapist Jerilyn Ross, director of the Ross Center for Anxiety and Related Disorders in Washington, DC.
"In the past, people with GAD were dismissed as hypochondriacs or simply excessive worriers," Ross says. "They didn't know they had a mental health problem that could be treated." Ross, president and CEO of the Anxiety Disorders Association of America, is also the author of Triumph Over Fear: A Book of Help and Hope for People With Anxiety, Panic Attacks and Phobias.
GAD sufferers are often acutely aware of their anxiety problem but don't know how to fix it -- or that it can be treated successfully, experts say. "They're aware that they're worrying irrationally, but just can't seem to shut it off," Ross says. "They're constantly fighting with themselves and hugely uncomfortable all of the time -- like a 78 record that gets stuck."
The disorder often coexists with depression, which can make an accurate diagnosis confusing, experts say. The picture is further complicated by the fact that a range of disorders can include anxiety as one of their symptoms: panic attacks, post-traumatic stress syndrome, social anxiety, and phobias. Patients may also develop addictions to drugs or alcohol when they try to inappropriately "medicate" their symptoms. "There's less agreement on how to accurately diagnose GAD as compared to other anxiety disorders," Spiegel says. "One doctor might diagnose GAD while another doctor might not be using the same criteria."
In Tilford's case, because she also suffers from depression, it took years to get a GAD diagnosis. "Back then, therapists were not trained in the area of fear," she says. "You go through the yellow pages now, and every other therapist lists anxiety or panic attacks as specialties."
How people get it
The mental health community hasn't been able to precisely pinpoint the causes of GAD. One theory is that some people may be born with a susceptibility to anxiety disorders. Psychological traumas during childhood -- such as death of a loved one or separation from parents -- may make people more vulnerable as well. Stressful events later in life can also trigger or contribute to anxiety.
Tilford wonders if her anxiety was triggered by her father's death when she was 10. She recalls having insomnia back then because she missed having her father read to her every night before she went to sleep.
Although GAD affects people of all ages, most can trace its beginnings back to childhood, adolescence, or early adulthood. Parents who overprotect or control their children, Spiegel says, may also be a factor, in effect passing on their anxiety and nervousness to their offspring.
"Often parents who are very well meaning, to prevent unhappiness, overprotect their children," he says. "But if children are not given the opportunity to explore, make mistakes, and develop self-confidence, as they grow up they will feel unprepared to cope with the world."
Experts say twice as many women as men are diagnosed with GAD. Hormonal differences may play a role. Girls also tend to be more overprotected in childhood and traditionally have had fewer opportunities as adults to exercise their power. According to the Harvard Health Letter, women seek mental health treatment more frequently than men do, which may skew the figures. (Men tend to control their anxiety by drinking alcohol.)
How GAD is treated
Despite the disorder's complex origins, treatment is usually quite effective, say experts. There are three main approaches, often used in combination: talk therapy, including cognitive behavioral therapy, medication, and relaxation training.
Many mental health professionals treat anxiety disorders through cognitive behavioral therapy, which aims to change unhealthy thought patterns. To do so, therapists challenge negative thinking and beliefs and guide patients in replacing them with more positive thoughts and behaviors. The patient learns to evaluate risks in life more accurately and realistically and acquire new coping behaviors. Typically the treatment takes about 12 to 15 sessions.
Other psychotherapists believe that discovering and understanding the sources of chronic anxiety can also be very useful to patients with GAD. In this model, therapists work with patients over time to process traumatic events and explore childhood fears and secrets that may be contributing to their current condition.
In addition, a number of medications are currently prescribed for the disorder -- including selective serotonin reuptake inhibitors or SSRIs (Paxil, Zoloft) and certain other antidepressants (Tofranil, Serzone, Effexor). The anti-anxiety drug BuSpar is the only drug approved specifically for GAD.
Relaxation techniques such as meditation and breathing exercises can also give patients some tools to help control their worrying and sleep more peacefully.
Although patients do very well with treatment, only 25 percent of those who have GAD seek care, experts say. People may not know they have a treatable anxiety disorder or may go to a health professional unfamiliar with its symptoms. Some fear being stigmatized as having a mental illness. "People are still embarrassed to ask for help for a mental health problem," says Ross. Or if they do, "they're sometimes passed on from doctor to doctor and test to test and dismissed for lack of medical symptoms. They're told there's nothing wrong ... and they suffer in silence."
If you suspect you have GAD, persevere until you get the right kind of help, experts say. "It is real, it is serious, it can be treated, and it's not something to be ashamed of," says Ross. "It doesn't mean you have a weakness in your character. It's just how your mind and body work. And if the first treatment doesn't work, don't give up."
Tilford, who gained significant control over her anxiety, is a firm believer in not giving up. She saw several therapists two decades ago when the disorder first surfaced, but back then they were of little help. Through friends, a good support network, and books on anxiety, she's largely taught herself how to handle her fears.
She's working at home now and is hoping to go back into the work world soon. And she's been driving for several years. Using techniques common to anxiety disorder workshops, Tilford desensitized herself to the panic of driving a car over a period of months -- first she touched the outside of the car, then, days later, she sat in the driver's seat until she could do it without severe anxiety. Weeks after that, when she was comfortable in the driver's seat, she practiced turning on the ignition, until at last she could actually get behind the wheel and drive to the corner and back. As a reward, three years ago she bought herself a new car.
"I am working to do something once a week that I've never done before," she says. "What you need is to do a little bit at a time and draw from your successes."
National Institute of Mental Health. The Numbers Count: Mental Disorders in America. February 2006. http://www.nimh.nih.gov/publicat/numbers.cfm
New England Journal of Medicine. Generalized Anxiety Disorder. Volume 351:675-682, Number 7. August 12, 2004. http://content.nejm.org/cgi/content/extract/351/7/675
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