Anxiety

I
INTRODUCTION
Anxiety, emotional state in which people feel uneasy, apprehensive, or fearful. People usually experience anxiety about events they cannot control or predict, or about events that seem threatening or dangerous. For example, students taking an important test may feel anxious because they cannot predict the test questions or feel certain of a good grade. People often use the words fear and anxiety to describe the same thing. Fear also describes a reaction to immediate danger characterized by a strong desire to escape the situation.
The physical symptoms of anxiety reflect a chronic “readiness” to deal with some future threat. These symptoms may include fidgeting, muscle tension, sleeping problems, and headaches. Higher levels of anxiety may produce such symptoms as rapid heartbeat, sweating, increased blood pressure, nausea, and dizziness.
All people experience anxiety to some degree. Most people feel anxious when faced with a new situation, such as a first date, or when trying to do something well, such as give a public speech. A mild to moderate amount of anxiety in these situations is normal and even beneficial. Anxiety can motivate people to prepare for an upcoming event and can help keep them focused on the task at hand.
However, too little anxiety or too much anxiety can cause problems. Individuals who feel no anxiety when faced with an important situation may lack alertness and focus. On the other hand, individuals who experience an abnormally high amount of anxiety often feel overwhelmed, immobilized, and unable to accomplish the task at hand. People with too much anxiety often suffer from one of the anxiety disorders, a group of mental illnesses. In fact, more people experience anxiety disorders than any other type of mental illness. A survey of people aged 15 to 54 in the United States found that about 17 percent of this population suffers from an anxiety disorder during any given year.
II
ANXIETY DISORDERS
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, a handbook for mental health professionals, describes a variety of anxiety disorders. These include generalized anxiety disorder, phobias, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder.
A
Generalized Anxiety Disorder
People with generalized anxiety disorder feel anxious most of the time. They worry excessively about routine events or circumstances in their lives. Their worries often relate to finances, family, personal health, and relationships with others. Although they recognize their anxiety as irrational or out of proportion to actual events, they feel unable to control their worrying. For example, they may worry uncontrollably and intensely about money despite evidence that their financial situation is stable. Children with this disorder typically worry about their performance at school or about catastrophic events, such as tornadoes, earthquakes, and nuclear war.
People with generalized anxiety disorder often find that their worries interfere with their ability to function at work or concentrate on tasks. Physical symptoms, such as disturbed sleep, irritability, muscle aches, and tension, may accompany the anxiety. To receive a diagnosis of this disorder, individuals must have experienced its symptoms for at least six months.
Generalized anxiety disorder affects about 3 percent of people in the general population in any given year. From 55 to 66 percent of people with this disorder are female.
B
Phobias
A phobia is an excessive, enduring fear of clearly defined objects or situations that interferes with a person’s normal functioning. Although they know their fear is irrational, people with phobias always try to avoid the source of their fear. Common phobias include fear of heights (acrophobia), fear of enclosed places (claustrophobia), fear of insects, snakes, or other animals, and fear of air travel. Social phobias involve a fear of performing, of critical evaluation, or of being embarrassed in front of other people.
C
Panic Disorder
Panic is an intense, overpowering surge of fear. People with panic disorder experience panic attacks—periods of quickly escalating, intense fear and discomfort accompanied by such physical symptoms as rapid heartbeat, trembling, shortness of breath, dizziness, and nausea. Because people with this disorder cannot predict when these attacks will strike, they develop anxiety about having additional panic attacks and may limit their activities outside the home.
D
Obsessive-Compulsive Disorder
In obsessive-compulsive disorder, people persistently experience certain intrusive thoughts or images (obsessions) or feel compelled to perform certain behaviors (compulsions). Obsessions may include unwanted thoughts about inadvertently poisoning others or injuring a pedestrian while driving. Common compulsions include repetitive hand washing or such mental acts as repeated counting. People with this disorder often perform compulsions to reduce the anxiety produced by their obsessions. The obsessions and compulsions significantly interfere with their ability to function and may consume a great deal of time.
E
Post-Traumatic Stress Disorder
Post-traumatic stress disorder sometimes occurs after people experience traumatic or catastrophic events, such as physical or sexual assaults, natural disasters, accidents, and wars. People with this disorder relive the traumatic event through recurrent dreams or intrusive memories called flashbacks. They avoid things or places associated with the trauma and may feel emotionally detached or estranged from others. Other symptoms may include difficulty sleeping, irritability, and trouble concentrating.
III
CAUSES
Most anxiety disorders do not have an obvious cause. They result from a combination of biological, psychological, and social factors.
A
Genetics and Neurobiology
Studies suggest that anxiety disorders run in families. That is, children and close relatives of people with disorders are more likely than most to develop anxiety disorders. Some people may inherit genes that make them particularly vulnerable to anxiety. These genes do not necessarily cause people to be anxious, but the genes may increase the risk of anxiety disorders when certain psychological and social factors are also present.
Anxiety also appears to be related to certain brain functions. Chemicals in the brain called neurotransmitters enable neurons, or brain cells, to communicate with each other. One neurotransmitter, gamma-amino butyric acid (GABA), appears to play a role in regulating one’s level of anxiety. Lower levels of GABA are associated with higher levels of anxiety. Some studies suggest that the neurotransmitters norepinephrine and serotonin play a role in panic disorder.
B
Psychological Factors
Psychologists have proposed a variety of models to explain anxiety. Austrian psychoanalyst Sigmund Freud suggested that anxiety results from internal, unconscious conflicts. He believed that a person’s mind represses wishes and fantasies about which the person feels uncomfortable. This repression, Freud believed, results in anxiety disorders, which he called neuroses.
More recently, behavioral researchers have challenged Freud’s model of anxiety. They believe one’s anxiety level relates to how much a person believes events can be predicted or controlled. Children who have little control over events, perhaps because of overprotective parents, may have little confidence in their ability to handle problems as adults. This lack of confidence can lead to increased anxiety.
Behavioral theorists also believe that children may learn anxiety from a role model, such as a parent. By observing their parent’s anxious response to difficult situations, the child may learn a similar anxious response. A child may also learn anxiety as a conditioned response. For example, an infant often startled by a loud noise while playing with a toy may become anxious just at the sight of the toy. Some experts suggest that people with a high level of anxiety misinterpret normal events as threatening. For instance, they may believe their rapid heartbeat indicates they are experiencing a panic attack when in reality it may be the result of exercise.
C
Social Factors
While some people may be biologically and psychologically predisposed to feel anxious, most anxiety is triggered by social factors. Many people feel anxious in response to stress, such as a divorce, starting a new job, or moving. Also, how a person expresses anxiety appears to be shaped by social factors. For example, many cultures accept the expression of anxiety and emotion in women, but expect more reserved emotional displays from men.
IV
TREATMENT
Mental health professionals use a variety of methods to help people overcome anxiety disorders. These include psychoactive drugs and psychotherapy, particularly behavior therapy. Other techniques, such as exercise, hypnosis, meditation, and biofeedback, may also prove helpful.
A
Medications
Psychiatrists often prescribe benzodiazepines, a group of tranquilizing drugs, to reduce anxiety in people with high levels of anxiety. Benzodiazepines help to reduce anxiety by stimulating the GABA neurotransmitter system. Common benzodiazepines include alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium). Two classes of antidepressant drugs—tricyclics and selective serotonin reuptake inhibitors (SSRIs)—also have proven effective in treating certain anxiety disorders.
Benzodiazepines can work quickly with few unpleasant side effects, but they can also be addictive. In addition, benzodiazepines can slow down or impair motor behavior or thinking and must be used with caution, particularly in elderly persons. SSRIs take longer to work than the benzodiazepines but are not addictive. Some people experience anxiety symptoms again when they stop taking the medications.
B
Psychotherapy
Therapists who attribute the cause of anxiety to unconscious, internal conflicts may use psychoanalysis to help people understand and resolve their conflicts. Other types of psychotherapy, such as cognitive-behavioral therapy, have proven effective in treating anxiety disorders. In cognitive-behavioral therapy, the therapist often educates the person about the nature of his or her particular anxiety disorder. Then, the therapist may help the person challenge irrational thoughts that lead to anxiety. For example, to treat a person with a snake phobia, a therapist might gradually expose the person to snakes, beginning with pictures of snakes and progressing to rubber snakes and real snakes. The patient can use relaxation techniques acquired in therapy to overcome the fear of snakes.
Research has shown psychotherapy to be as effective or more effective than medications in treating many anxiety disorders. Psychotherapy may also provide more lasting benefits than medications when patients discontinue treatment.

Bipolar Disorder

I
INTRODUCTION
Bipolar Disorder, mental illness in which a person’s mood alternates between extreme mania and depression. Bipolar disorder is also called manic-depressive illness. When manic, people with bipolar disorder feel intensely elated, self-important, energetic, and irritable. When depressed, they experience painful sadness, negative thinking, and indifference to things that used to bring them happiness.
II
PREVALENCE
Bipolar disorder is much less common than depression. In North America and Europe, about 1 percent of people experience bipolar disorder during their lives. Rates of bipolar disorder are similar throughout the world. In comparison, at least 8 percent of people experience serious depression during their lives. Bipolar disorder affects men and women about equally and is somewhat more common in higher socioeconomic classes. At least 15 percent of people with bipolar disorder commit suicide. This rate roughly equals the rate for people with major depression, the most severe form of depression.
Some research suggests that highly creative people—such as artists, composers, writers, and poets—show unusually high rates of bipolar disorder, and that periods of mania fuel their creativity. Famous artists and writers who probably suffered from bipolar disorder include poets Lord Byron and Anne Sexton, novelists Virginia Woolf and Ernest Hemingway, composers Peter Ilyich Tchaikovsky and Sergey Rachmaninoff, and painters Amedeo Modigliani and Jackson Pollock. Critics of this research note that many creative people do not suffer from bipolar disorder, and that most people with bipolar disorder are not especially creative.
III
SYMPTOMS
Bipolar disorder usually begins in a person’s late teens or 20s. Men usually experience mania as the first mood episode, whereas women typically experience depression first. Episodes of mania and depression usually last from several weeks to several months. On average, people with untreated bipolar disorder experience four episodes of mania or depression over any ten-year period. Many people with bipolar disorder function normally between episodes. In “rapid-cycling” bipolar disorder, however, which represents 5 to 15 percent of all cases, a person experiences four or more mood episodes within a year and may have little or no normal functioning in between episodes. In rare cases, swings between mania and depression occur over a period of days.
In another type of bipolar disorder, a person experiences major depression and hypomanic episodes, or episodes of milder mania. In a related disorder called cyclothymic disorder, a person’s mood alternates between mild depression and mild mania. Some people with cyclothymic disorder later develop full-blown bipolar disorder. Bipolar disorder may also follow a seasonal pattern, with a person typically experiencing depression in the fall and winter and mania in the spring or summer
People in the depressive phase of bipolar disorder feel intensely sad or profoundly indifferent to work, activities, and people that once brought them pleasure. They think slowly, concentrate poorly, feel tired, and experience changes—usually an increase—in their appetite and sleep. They often feel a sense of worthlessness or helplessness. In addition, they may feel pessimistic or hopeless about the future and may think about or attempt suicide. In some cases of severe depression, people may experience psychotic symptoms, such as delusions (false beliefs) or hallucinations (false sensory perceptions).
In the manic phase of bipolar disorder, people feel intensely and inappropriately happy, self-important, and irritable. In this highly energized state they sleep less, have racing thoughts, and talk in rapid-fire speech that goes off in many directions. They have inflated self-esteem and confidence and may even have delusions of grandeur. Mania may make people impatient and abrasive, and when frustrated, physically abusive. They often behave in socially inappropriate ways, think irrationally, and show impaired judgment. For example, they may take airplane trips all over the country, make indecent sexual advances, and formulate grandiose plans involving indiscriminate investments of money. The self-destructive behavior of mania includes excessive gambling, buying outrageously expensive gifts, abusing alcohol or other drugs, and provoking confrontations with obnoxious or combative behavior.
IV
CAUSES
The genes that a person inherits seem to have a strong influence on whether the person will develop bipolar disorder. Studies of twins provide evidence for this genetic influence. Among genetically identical twins where one twin has bipolar disorder, the other twin has the disorder in more than 70 percent of cases. But among pairs of fraternal twins, who have about half their genes in common, both twins have bipolar disorder in less than 15 percent of cases in which one twin has the disorder. The degree of genetic similarity seems to account for the difference between identical and fraternal twins. Further evidence for a genetic influence comes from studies of adopted children with bipolar disorder. These studies show that biological relatives of the children have a higher incidence of bipolar disorder than do people in the general population. Thus, bipolar disorder seems to run in families for genetic reasons.
Personal or work-related stress can trigger a manic episode, but this usually occurs in people with a genetic vulnerability. Other factors—such as prenatal development, childhood experiences, and social conditions—seem to have relatively little influence in causing bipolar disorder. One study examined the children of identical twins in which only one member of each pair of twins had bipolar disorder. The study found that regardless of whether the parent had bipolar disorder or not, all of the children had the same high 10-percent rate of bipolar disorder. This observation clearly suggests that risk for bipolar illness comes from genetic influence, not from exposure to a parent’s bipolar illness or from family problems caused by that illness.
V
TREATMENT
Different therapies may shorten, delay, or even prevent the extreme moods caused by bipolar disorder. Lithium carbonate, a natural mineral salt, can help control both mania and depression in bipolar disorder. The drug generally takes two to three weeks to become effective. People with bipolar disorder may take lithium during periods of relatively normal mood to delay or prevent subsequent episodes of mania or depression. Common side effects of lithium include nausea, increased thirst and urination, vertigo, loss of appetite, and muscle weakness. In addition, long-term use can impair functioning of the kidneys. For this reason, doctors do not prescribe lithium to bipolar patients with kidney disease. Many people find the side effects so unpleasant that they stop taking the medication, which often results in relapse.
From 20 to 40 percent of people do not respond to lithium therapy. For these people, two anticonvulsant drugs may help dampen severe manic episodes: carbamazepine (Tegretol) and valproate (Depakene). The use of traditional antidepressants to treat bipolar disorder carries risks of triggering a manic episode or a rapid-cycling pattern.

Conduct Disorder

Children with conduct disorder repeatedly violate the personal or property rights of others and the basic expectations of society. A diagnosis of conduct disorder is likely when symptoms continue for 6 months or longer. Conduct disorder is known as a "disruptive behavior disorder" because of its impact on children and their families, neighbors, and schools.Another disruptive behavior disorder, called oppositional defiant disorder, may be a precursor of conduct disorder. A child is diagnosed with oppositional defiant disorder when he or she shows signs of being hostile and defiant for at least 6 months. Oppositional defiant disorder may start as early as the preschool years, while conduct disorder generally appears when children are older. Oppositional defiant disorder and conduct disorder are not co-occurring conditions.What are the signs of conduct disorder?
Symptoms of conduct disorder include:
· Aggressive behavior that harms or threatens other people or animals;
· Destructive behavior that damages or destroys property;
· Lying or theft;
· Truancy or other serious violations of rules;
· Early tobacco, alcohol, and substance use and abuse; and
· Precocious sexual activity.
Children with conduct disorder or oppositional defiant disorder also may experience:
· Higher rates of depression, suicidal thoughts, suicide attempts, and suicide;
· Academic difficulties;
· Poor relationships with peers or adults;
· Sexually transmitted diseases;
· Difficulty staying in adoptive, foster, or group homes; and
· Higher rates of injuries, school expulsions, and problems with the law.
How common is conduct disorder?
Conduct disorder affects 1 to 4 percent of 9- to 17-year-olds, depending on exactly how the disorder is defined (U.S. Department of Health and Human Services, 1999). The disorder appears to be more common in boys than in girls and more common in cities than in rural areas.



Who is at risk for conduct disorder?
Research shows that some cases of conduct disorder begin in early childhood, often by the preschool years. In fact, some infants who are especially "fussy" appear to be at risk for developing conduct disorder. Other factors that may make a child more likely to develop conduct disorder include:
· Early maternal rejection;
· Separation from parents, without an adequate alternative caregiver;
· Early institutionalization;
· Family neglect;
· Abuse or violence;
· Parental mental illness;
· Parental marital discord;
· Large family size;
· Crowding; and
· Poverty.
What help is available for families?
Although conduct disorder is one of the most difficult behavior disorders to treat, young people often benefit from a range of services that include:
· Training for parents on how to handle child or adolescent behavior.
· Family therapy.
· Training in problem solving skills for children or adolescents.
· Community-based services that focus on the young person within the context of family and community influences.
What can parents do?
Some child and adolescent behaviors are hard to change after they have become ingrained. Therefore, the earlier the conduct disorder is identified and treated, the better the chance for success. Most children or adolescents with conduct disorder are probably reacting to events and situations in their lives. Some recent studies have focused on promising ways to prevent conduct disorder among at-risk children and adolescents. In addition, more research is needed to determine if biology is a factor in conduct disorder.Parents or other caregivers who notice signs of conduct disorder or oppositional defiant disorder in a child or adolescent should:
· Pay careful attention to the signs, try to understand the underlying reasons, and then try to improve the situation.
· If necessary, talk with a mental health or social services professional, such as a teacher, counselor, psychiatrist, or psychologist specializing in childhood and adolescent disorders.