Jerilyn Ross is one of the nation’s leading experts on anxiety disorders. In her new book, “One Less Thing to Worry About,” she explains the difference between having normal worries and having an anxiety disorder that interferes with your quality of life. An excerpt.
‘Am I just a worrier, or is there something wrong with me?’
Most of us would agree that a young mother’s anxiety is probably normal when, for example, she’s not sure she’s holding her baby correctly when she burps him, whether his rash is a sign of a serious illness, or what to do when he won’t stop crying. However, if the same young mother refuses to be alone with her child for fear of harming him, won’t pick him up because she’s afraid she might have germs on her hands and will contaminate him, or is afraid to call the pediatrician when her child is running a fever for fear of saying the wrong thing and making a fool of herself, she may indeed have an anxiety disorder.
Most of the time, the difference is obvious, especially to the person with the problem. The young mother who won’t pick up her baby is aware that her behavior is irrational yet feels powerless to change it. She may go to great lengths to hide the seemingly senseless and often embarrassing behavior, making excuses for why she cannot pick up the baby after she’s touched something she considers “germy” — complaining of back pain, for instance — and manipulating her husband, friends, and family members into doing it for her.
At times the person may try to justify the behavior to herself, even though she is aware that the anxiety doesn’t make sense. For example, a young woman who refuses to be alone with her child for fear of harming her might think, I know there is no way in a million years I would or could ever harm my child, but there’s no telling what might happen when that awful feeling comes over me — I just can’t risk losing control. Yes, the feeling is terrifying, but as I tell my patients, although the feeling is frightening, it is not dangerous. People with anxiety disorders have scary thoughts, but they’re just that — thoughts that have gone awry. They are not predictors of imminent actions. They are just thoughts; and thoughts alone, however scary, don’t make people do things they don’t want to do.
So if you have irrational, anxious thoughts about places, objects, or situations that pose no real threat of danger and that lead you to behave in ways that you perceive as irrational, you may have an anxiety disorder. We’ll talk more about the specific symptoms of the different types of anxiety disorders later in this chapter, but for now, let’s continue with getting a clearer picture of what is and what is not normal anxiety.
Whereas we have language to describe the symptoms and manifestations of anxiety in general, we have no reliable diagnostic tools to measure the nature and severity of any one person’s experience of it. There aren’t any blood tests or X-rays that can tell me, for example, how the intensity of one person’s panic attack compares to that of another, although we are moving in that direction. Researchers at Massachusetts General Hospital have found that the brains of people with post-traumatic stress disorder and those who suffer from a phobia manifest atypical activity in the areas that deal with fear, suggesting that such people experience apprehension more intensely than the rest of us.And Jill M. Hooley, Ph.D., at Harvard has found scientific evidence of what a lot of us have known since we were kids: that the brain’s anxiety mechanism starts cranking when people listen to an audiotape of a parent criticizing them.
That said, one way to approach the issue is to ask yourself: “To what extent is anxiety interfering in my life?” Do you feel uncomfortable whenever you enter an elevator but stay on anyway, or did you quit your job when you learned your company was moving to a high- rise building? Do you make a point of washing your hands before eating and after taking the subway, or do you feel compelled to scrub them every time you touch a doorknob or shake hands with someone? Do you sometimes have trouble falling asleep after a rough day at work, or do you have chronic insomnia that leaves you perpetually exhausted no matter how your day goes?
You might also want to ask yourself whether or not you believe your anxiety is rational. Sure, it makes sense to be apprehensive about driving over an icy bridge at three in the morning in the midst of a hailstorm. But is it rational to drive half an hour out of your way, morning and evening, to avoid a bridge that, if you took it, would cut your commute in half? And no one would argue that chest pain, heart palpitations, and hyperventilation are signals that you should get yourself seen by a doctor right away. But something is awry when a healthy twenty-five-year-old woman with no family history of cardiovascular disease ends up in the emergency room five times in three weeks convinced that she is having a heart attack, even though each visit ends with the doctor assuring her, based on extensive (not to mention expensive) tests, that there is nothing wrong with her heart.
Is your anxiety causing you to make significant changes in the way you conduct your life? Do you find yourself catering to your anxiety, changing the things you do or the way you do them in an attempt to allay the unpleasant feelings? I am not suggesting, mind you, that there aren’t very good reasons to make changes in your life. You would probably agree that it would make sense to cancel a romantic getaway weekend with your husband if your daughter had been running a fever for three days and you felt it was neither wise nor considerate to leave her with your elderly in-laws, or because the government had just issued a terror alert for the country you were planning to visit. But you might not agree that the actions of one of my patients made sense when, some years ago, she canceled an anniversary trip to a resort in Acapulco because a guidebook mentioned that there were numerous stray cats in the city. This woman was so phobic about cats that the thought of even glimpsing one was enough to make her forgo a vacation she had been planning for months and anticipating for years.
Similarly, you wouldn’t question the anxiety you might feel about getting back onto a ski lift after the last ride up the mountain left you dangling in midair for thirty minutes, driving home alone at night after some thugs threw beer cans at your car window, or moments after the school nurse called to tell you that she was pretty sure the fall your child took on the playground didn’t cause a concussion. Each of these scenarios presents circumstances under which a stable, well-adjusted person would have sufficient reason to feel anxious. But what if your anxiety didn’t make sense to anyone, including you? What if it was so pervasive and chronic that it led you to make decisions that were detrimental to your career, your family, your social life, or all of the above?
That’s what was happening to Melissa, who first came in for treatment in January 2003. She was thirty-two and worked as an assistant buyer of women’s accessories for an upscale department store. She was married and the mother of a nine-year-old boy, and, except for a slight rash on her neck that reddened as she spoke, appeared to be the picture of health and self-confidence. I asked her what had brought her in to see me.
“My anxiety is running my life,” she said. “I wake up with it and I go to sleep with it, although I usually don’t stay asleep very long. I worry about everything. I mean everything. Sometimes I feel like there’s a motor inside my body that just won’t stop. And the craziest part is that most people look at me, my life, my job, my family, and think I don’t have a care in the world!”
But they were wrong. Melissa fretted about her son, Cody (What if he lost the quarters she had given him to buy a snack? What if he went outside for recess without his jacket? What if he didn’t eat enough for lunch? What if he ate too much for lunch? What if he didn’t eat lunch at all?); her husband (What if he forgot to stop at the pharmacy and pick up his prescription? What if he had a car accident on the way to work? What if the pain in his back was something really serious?); her brother; her sister; and her parents (Did they remember what they were each supposed to bring to Christmas dinner? Would they allow enough time to get there in holiday traffic?); and the innumerable variables that constitute modern life (What if the airline canceled their flight and they missed her niece’s confirmation? What if the pediatrician had vaccinated Cody with expired chicken pox vaccine and it didn’t work — hadn’t she just read something about that in a magazine?).
As I listened to Melissa talk, I was struck by how much insight she had regarding the things that were making her anxious and how aware she was that 95 percent of her anxiety was, as she put it, totally, undeniably irrational.
“Over the last six years I’ve been to four hospital emergency rooms and every ‘-ologist’ you can think of,” she said. She had seen not one but two cardiologists because she needed a second opinion after the first one said her heart palpitations were most likely anxiety-related, and then she consulted a neurologist who confirmed what she secretly believed: that both her frequent headaches and her difficulty concentrating on even menial tasks were due not to neurological problems but rather to stress. Some months earlier she had made an appointment with a gastroenterologist because a friend had been diagnosed with irritable bowel syndrome and Melissa thought perhaps she had it too since she had been having a lot of indigestion and upset stomachs (the doctor gave her some antacid samples, and, shortly afterward, the symptoms abated and had not returned). She had made an appointment with an endocrinologist for the week after she first came to see me and was hoping he would diagnose her with hyperthyroidism, which would at least explain her palpitations, skittishness, and fatigue.
Like many women with chronic, severe anxiety, Melissa had had the “million-dollar workup” and emerged with a clean bill of health among dozens of other bills. Ironically, during all the years of running from doctor to doctor she recalls only one who recommended she get psychiatric help, although after telling me this she backpedaled and admitted that others might have said the same thing, only she hadn’t been ready to hear it.
You’ve got to understand,” she said, “I’m not making this stuff up — the headaches are real; the palpitations are real; the breathlessness is real. It’s not just in my head.”
“Isn’t your head part of your body?” I asked.
Melissa and I discussed her symptoms, but before making a diagnosis and developing a treatment plan I needed more information: family history (“My mother and her mother were ‘total worriers’ ”); caffeine intake (three to four cups of coffee a day); alcohol use (“None —I hate feeling out of control”); what types of situations made her tense, worried, or nervous (“Are you kidding? What doesn’t make me nervous?”). Had her career been affected by it? (“Oh, yes; I should have lost the ‘assistant’ part of my title over two years ago, but I’ve taken so much sick leave that I haven’t been promoted.”) How about her relationship with her husband and son?
“How many days during the past six months would you say that you’ve experienced excessive anxiety and worry?” I asked.
“I would say ...” Melissa closed her eyes briefly before answering. “You know, I can’t remember a single day when I didn’t feel anxious.”
“Are there specific events or activities that are especially worrisome to you?” This unleashed a barrage of worries.
“I know Dan is faithful and I hate myself for thinking this, but sometimes when he comes home late I start wondering if maybe he’s having an affair.”
“What do you do when you have thoughts like that?”
“I’m embarrassed to admit this, but I call his cell phone and make up an excuse about why I’m calling. Then I start a conversation and try to find out exactly where he is.”
“And when he tells you he’s at the office, do you believe him?”
“Well, yes, but ... this is so stupid, but even though I know that he is where he says he is, sometimes I start getting heart palpitations and I get all sweaty and my mind starts racing and thinking that he’s not telling the truth.”
“What do you do about it?”
“This is so embarrassing. I don’t know if I can say it.”
“That’s fine; you don’t have to unless you want to.” She paused for a moment. Her face was flushed when she spoke again.
“Okay. Here goes. One time, I actually went online and looked up the extensions of everyone in Dan’s department. Then I started calling around until this woman picked up the phone and I made up a phony name and asked if Dan was there. So she’s like, ‘You’ve got the wrong extension, but he’s in his office so hold on and I’ll transfer you —’ and I hung up.
“And that’s not all. One time I actually drove by his office to see if his car was still there. I put Cody in the car and drove around the back of the building until I saw his car, and then I drove home. Now, I realize this is totally crazy. I don’t believe for a minute that my husband would cheat on me. He’s never given me any reason to suspect he would do something like that. Intellectually, I know my anxiety is crazy. But I still can’t stop the negative thoughts from creeping into my head and taking over my body.”
“Are there other things you worry about that you know aren’t really a danger to you?”
“Absolutely. I worry that we won’t be able to save enough money to send Cody to college. This is also crazy because Dan and I make decent salaries and we’ve already put quite a bit of money away for college. The other night I actually had what I think is a panic attack in the middle of the night. I’m lying there thinking, What if something happens to Dan or me and we can’t work anymore and we have to use Cody’s college fund to pay the mortgage? and on and on until I was a ball of sweat and had to get out of bed and walk around until I calmed down. And it’s not as if Cody is leaving for college any time soon; he’s only nine years old!”
Lack of sleep made Melissa exhausted all day, which then made her cranky and irritable all evening. When Dan recommended they go jogging together as an antianxiety activity, Melissa said she would give it a try. But their ?first time out she went a few blocks, became short of breath, and panicked, thinking she was having a heart attack. She hadn’t put on her running shoes since.
Although Melissa felt beaten up by her anxiety, she was not clinically depressed. Sure, she said, there were times she felt she just couldn’t stand feeling this way, but she never felt hopeless or so down that she couldn’t function. I asked if she had ever had suicidal thoughts.
“No — never,” she said. “Why would I want to kill myself? It’s not that I don’t want to be alive; it’s just that it’s so hard. At times I look around me and think, I’m so much better off than most people: I have a good marriage, a wonderful kid, a nice house, and work I enjoy. So why does everyone else look so calm and relaxed and I always feel like I’m about to disintegrate? You know, I’m so accustomed to feeling anxious that I can’t even imagine what it would be like not to feel that way and to not always be worried about being worried.”
It didn’t take long for me to diagnose Melissa with generalized anxiety disorder (GAD). Unlike the everyday, normal anxiety we all feel from time to time, the physical and psychological symptoms associated with GAD are often so intense that they stop people from doing the very things they want and often love to do. In Melissa’s case, her inability to concentrate, frequent headaches, and insomnia- related fatigue were interfering with her ability to keep up with the demands of her job and get promoted to a better one. That’s what had finally driven her into my office (along with an event I’ll describe later). She knew that her relentless anxiety and anxiety-related symptoms were different from those that many women feel while trying to juggle motherhood and career; she actually felt she had those areas well under control. I trusted Melissa when she described how helpful her husband was with their son; how well adjusted, mature, and independent Cody was; and how tolerant her boss was when she took time off for doctor visits or because she was too exhausted to work. Melissa’s anxiety was not, as far as I could see, related to her lifestyle. She clearly had an anxiety disorder: GAD.
Everyday anxiety or anxiety disorder?
So what exactly is an anxiety disorder? It’s an umbrella term for a group of conditions that involve chronic, excessive, inexplicable anxiety that interferes with the way a person conducts his or her daily life. Under the umbrella are generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Each of these conditions has a different constellation of symptoms, although some symptoms are common to several disorders. For instance, the pounding heart, shallow breathing, and excessive perspiration associated with panic disorder may also be familiar to someone who suffers from a specific phobia or social phobia. It is also common for a person to have more than one anxiety disorder, the varieties of which are as follows:
• As we established, Melissa is suffering from generalized anxiety disorder (GAD). People who suffer from GAD are beset by persistent, excessive, and unrealistic worry that they are unable to control and that focuses on everyday things such as health, career, ﬁfinances, relationships, and the security and well-being of their loved ones. GAD symptoms differ from those of the garden-variety worrier in that the worry associated with GAD is relentless and ongoing, feels impossible to control, and occurs on more days than not for a minimum of six months. The worries of GAD are accompanied by physical symptoms, especially restlessness, difficulty falling asleep and staying asleep, becoming easily fatigued, headaches, difficulty concentrating, irritability, muscle tension with resulting pain, abdominal upsets, and dizziness. Nearly seven million American adults, or 2 percent of the U.S. population, suffer from GAD, with women twice as likely as men to develop it. Women with GAD tend to develop the disorder younger than men and are more likely than men to have other mental health problems, such as depression.
• Panic disorder is characterized by recurrent, spontaneous, seemingly out-of-the-blue panic attacks, whose symptoms may include heart palpitations, sweating, trembling, shortness of breath or a feeling of choking, dizziness, chills, and hot ﬂushes as well as fears of losing control, “going crazy” or dying, and feelings of imminent doom. Panic attacks manifest as abrupt onsets of intense terror that reach a peak within a few minutes. What differentiates someone with panic disorder from someone who experiences occasional panic attacks is the person’s state of mind between the attacks: with panic disorder, an attack is typically followed by at least one month of persistent concern about having another attack, worry about the consequences of an attack (such as losing control or having a heart attack), and/or a major change in behavior related to the attacks. Panic disorder affects twice as many women as men and is often accompanied by major depression. More than six million Americans — 2.7 percent of the adult population — suffer from panic disorder.
• Panic disorder with agoraphobia About one out of three people with panic disorder develops agoraphobia, an avoidance of places, typically open or public spaces, where one fears having a panic attack and being unable to immediately get to safety — for instance, when entering a theater or sports arena, waiting in line at the grocery store, or riding on public transportation. People with agoraphobia often start eliminating places they are willing to go as they relentlessly anticipate having a panic attack. In extreme cases, an agoraphobic’s world gradually shrinks until he or she is too fearful to leave the house. Women with panic disorder are more likely than men to develop agoraphobia.
• Specific or simple phobias are characterized by irrational, involuntary fear reactions to particular objects, places, or situations. As with the example of the kindergarten teacher and the accountant with a fear of elevators, people who suffer from a specific phobia dread encountering ordinary, everyday situations or objects even though they know the dread is irrational. Someone with a phobia may even have a panic attack when confronted with a dreaded object or situation and thereafter be loath to go back for fear of having another panic attack. Oftentimes, it is anticipatory anxiety — the anxiety you feel when anticipating an event rather than the anxiety you feel when experiencing the event — that keeps a person from confronting something she has no realistic fear of (driving through a tunnel, petting her neighbor’s kitten, riding on an escalator).
How can you tell the difference between a fear and a phobia? As stated earlier, if the aversion makes sense, it’s probably a fear. If the aversion and accompanying feelings are irrational, it’s probably a phobia. A person with a phobia fears the fear itself rather than the object of the fear and typically has difficulty exactly what he or she is afraid of. For example, if you ask someone with a fear of flying what she is afraid of, she will probably say “I’m afraid of crashing” or “I can’t stand turbulence” or “I’m terriﬁed we’ll be hijacked by terrorists.” Ask someone with a true ﬂying phobia the same question, however, and she will probably say, “I don’t know what I’m afraid of. What if I want to get off after we’re airborne?” or “What if I have a panic attack on the plane and lose control and start running up and down the aisle like a madwoman?” or “What if I have a heart attack and die on the plane?” The “what if?” questions and fear of the feelings or the fear itself are characteristic of a phobia.
• Social anxiety disorder, also known as social phobia, is characterized by an intense fear of one or several social or performance situations in which the person is exposed to unfamiliar people and/or to possible scrutiny and judgment by others. Physical symptoms may include blushing, nausea, trembling, profuse sweating, and difﬁculty talking. Some people with social phobia are terriﬁed of and make every effort to avoid speciﬁc situations requiring contact with others, such as speaking before an audience, making or receiving telephone calls, or signing their name in public. Others have a more generalized form of the disorder where they attempt to avoid or endure with great distress common, everyday social situations such as talking to authority ﬁgures (teachers, doctors, supervisors, police ofﬁcers), being the center of attention at a meeting or social gathering, expressing disapproval of or disagreement with people they don’t know well, or working while others are watching them. One of my patients, a twenty- year-old college freshman with the generalized type of social phobia, described his anxiety as affecting every aspect of his life and said, “The ﬁrst thing I think about every morning when I ﬁrst wake up is ‘Who am I going to have to say hello to today?’ ”
Social phobia is the most common anxiety disorder, affecting ﬁfteen million American adults. It’s the third most common psychiatric disorder in the country after depression and substance abuse, and, interestingly, it is one of the few psychiatric disorders where men are more likely to seek treatment than women. We don’t know for certain why this is the case, but one theory is that because it is less acceptable for men to be socially reticent than women, social anxiety poses more professional and personal difﬁculties for men, motivating them more to seek treatment.
• Obsessive-compulsive disorder (OCD) People who suffer from OCD are plagued by unwanted thoughts (obsessions) that intrude into their thinking. To ease the anxiety caused by these thoughts, they feel compelled to do certain things or perform ritualized acts (compulsions), all the while recognizing both the irrationality of their behavior and their inability to stop it. Common obsessions include constant, irrational worry about dirt, germs, or contamination; feelings that chaos will descend unless objects are positioned or a situation managed in a certain way; and apprehensiveness about disposing of items of little intrinsic value but that the person inexplicably feels she may someday need. Common compulsions include rituals associated with cleaning (repeated washing of hands or dusting and vacuuming); checking and rechecking (repeatedly making sure the door is locked, the iron unplugged, and the oven turned off before leaving the house); and hoarding (amassing excessive numbers of useful items such as dozens of bottles of shampoo or cases of soup or stockpiling useless items such as old newspapers and magazines or empty bottles and jars).
• Post-traumatic stress disorder (PTSD) is the one anxiety disorder that is rooted not in irrational fear but rather in an actual life-threatening event that the sufferer has either endured or witnessed. Once known as shell shock and used in reference to soldiers returning from battle with psychological disturbances, PTSD is diagnosed when a person is unable to recover from a traumatic experience (such as rape, physical abuse, or surviving a hurricane, tsunami, or earthquake) and continues to suffer from signiﬁcant anxiety and depression for months and sometimes years afterward. People with PTSD often relive the traumatic event through nightmares and ﬂashbacks and ﬁnd it difﬁcult if not impossible to concentrate, relax, or sleep undisturbed.
Excerpted from “One Less Thing to Worry About” by Jerilyn Ross. Copyright (c) 2009. Reprinted with permission from Random House.